AUTHORIZATION TO CONSENT FOR TREATMENT OF A MINOR

I grant permission to_______________________________________________   and/or

_______________________________________________________ to accompany my

child___________________________________________________ to Comprehensive

Pediatrics in my absence.  I hereby authorize this/these person(s) to give informed consent

to any medical care that is recommended by their health care provider during that visit.

This authorization does not expire unless revoked by me.

Signature of Parent                                                                                           Date

Address                                                                                                                     

Home Phone                                                                 Work Phone