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  • I, the undersigned parent, or legal guardian of the above-named child, hereby grant permission to accompany and represent me at my child's medical appointment for the purpose of receiving medical care and services.
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  • I understand and agree to the following:

    1. MPA is authorized to provide necessary medical care, examinations, and treatments to my child during this appointment.

    2. I understand that my family member, is acting as my authorized representative during the appointment and is authorized to provide consent for medical procedures as deemed necessary by the healthcare provider.

    3. I release and hold harmless MPA and their staff from any liability for any medical treatments or services provided to my child during the appointment.

    4. I grant permission for MPA to share any medical information related to this appointment.

    5. I hereby give my informed consent for my child to receive any recommended vaccines during the appointment. I understand that vaccines are an important part of preventive healthcare and will follow the healthcare provider's recommendations regarding vaccinations.

    6. I understand that this consent form is valid only for the specified appointment and does not grant ongoing or general consent for medical care in the future.

    7. I certify that the information provided on this form is accurate and complete to the best of my knowledge.

    8. I acknowledge that I have read and understood the information on this form and agree to all of its terms.

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  • This field is for validation purposes and should be left unchanged.