Medical Consent Form

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First Name

Last Name

Email Address

Cell Phone Number

Preferred Contact Method

What is Your Birthday?

By signing this consent, I am authorizing my physician and/or other individuals he or she deems appropriate to perform and/or order exams, tests, procedures, and any other care deemed necessary or advisable for the diagnosis and treatment of my medical condition. This consent is valid for each visit I make to Pro-Care Medical Center unless revoked by me in writing.

Full Name (Authorization)

Consent to Treatment of a Minor Child (

I authorize Pro-Care Medical Center to administer services deemed necessary to my minor child.

Patient/Legal Representative Authorization

My relation to the minor is: