General Consent to Treat

I am the parent/ guardian of (name of patient), I have the legal right to consent to medical and surgical treatment for this patient.

I voluntarily authorize and consent to such medical care, treatment, and diagnostic tests that Dr. Virginia Araiza and his/her designated associates or assistants believe are necessary for this child. I understand that by signing this form, I am giving permission to the doctors, physician assistants, and other healthcare providers in this medical office to provide treatment to this child as long as this child is a patient in this office, or until I withdraw my consent.

I have read this form or this form has been read to me in a language that I understand, and I have had an opportunity to ask questions about it.

Delegation of Consent

I hereby authorize (when I am unavailable to give consent) the following individual(s) to consent to any and all medical care and attention for this child which is deemed necessary and appropriate by a healthcare provider licensed in the state of Texas. This consent includes, but is not limited to, medical and surgical intervention, and elective as well as emergency care. This delegation shall be valid until I withdraw delegation of consent.

Those Whom Consent is Delegated:
Name Relation to patient
Signature of Parent / Guardian: Date:
Relation to Patient: Email:
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Pediatric services are available to all children; office visit fees can be billed to medical insurance or paid in cash.
A sliding schedule of fees for uninsured children is available. Contact us now for more information.
The information contained in this website is to provide information of a general nature about the
practice and pediatric medical conditions. Neither Dr. Leonhardt nor Bee Well Pediatrics, P.A. is engaged in rendering medical
advice or recommendations. You should always consult your doctor for advice.