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Cottonwood Pediatrics 700 Medical Center Dr, Ste 150 Newton KS 67114 316-283-7100 www.cottonwoodpeds.com Consent to Treat (For NON-PARENT caregivers of minor children when a parent is not present) TO AVOID DELAYS IN TREATMENT Please return this completed form by mail to the address above, or by fax to 316-283-7118, BEFORE the child’s appointment Child’s name Date of Birth When I/we, the undersigned parent(s) or legal guardian(s) of the child listed above, are not present, I/we authorize: who is Name of adult who is the NON-PARENT caregiver whom you are authorizing to give consent to treat to the child (grandparent, aunt, babysitter, etc.) and a caregiver of this child, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, immunizations, injections or treatment and/or hospital care to be provided to said child, when such services are recommended and supervised by Cottonwood Pediatrics..
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