Parental Consent Form

~ Online Submission Form ~

Please complete the form below if you are not able to be present with your child and wish to give consent for your child to receive medical care at our clinic. 

Child Name *

First

Last

Child's DOB *

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Child's Date of Birth

Parent Name *

First

Last

Parent's DOB (copy) *

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Parent's Date of Birth

Parent Email *

Parent Phone Number *

Parental Consent for Child to be seen in the absence of a parent and with another adult *

• Yes, I provide consent
• No, I do not provide consent

Name of Person Accompanying Child

First

Last

Date of Birth of Person Accompanying Child *

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Date of Birth of Person Accompanying Child

Upload Parent's Government Issued ID card

Click or drag a file to this area to upload.

I authorize San Fernando Pediatrics & Urgent Care’ providers to provide medical care for my child. In the event that my child is brought to the clinic by anyone other than a legal guardian or me, I authorize that my child may be treated in my absence. I understand that I am responsible for settling any costs arising from this care provided in my absence. The following person(s) have my permission to authorize medical care for my child and sign any necessary waivers on my behalf *

Clear Signature

Signature

Comment

Confirm & Submit