Medical Consent Form Thanks for stopping by. Please submit this form… First Name This is required. Last Name This is required. Email Address This is required. Cell Phone Number Preferred Contact Method Email Cell Phone (call/text) Home Phone 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) This is required. 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: Submit Consent
