# Consent Forms

## Patient Information
- **Patient Name:** _________________________
- **Date of Birth:** _________________________
- **Parent/Guardian Name:** _________________________

## Treatment Consent
☐ I consent to medical examination, diagnosis, and treatment for my child
☐ I consent to emergency medical treatment if I cannot be reached
☐ I consent to the administration of anesthesia if required
☐ I consent to surgical procedures if recommended by the physician

## Communication Consent
☐ I consent to receive phone calls regarding appointments and health information
☐ I consent to receive text messages for appointment reminders
☐ I consent to receive emails with health information
☐ I consent to receive voicemail messages

## Information Release Authorization
☐ I authorize the release of health information to my child's school
☐ I authorize the release of health information to other healthcare providers
☐ I authorize the release of health information to specified family members
☐ I authorize the release of health information to emergency contacts

## HIPAA Privacy Consent
☐ I acknowledge receipt of the Notice of Privacy Practices
☐ I understand my rights regarding my child's health information

## Additional Consents
☐ I consent to the administration of recommended vaccinations
☐ I consent to the administration of prescribed medications
☐ I consent to school health services
☐ I consent to photography for medical documentation purposes
☐ I consent to my child's participation in approved research studies

## Special Instructions
- **Special Instructions:** _________________________

## Digital Signature
- **Parent/Guardian Signature:** _________________________
- **Date:** _________________________

*By typing your name above, you are providing your digital signature and confirming that all information is accurate and complete.*

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*Rose Pediatrics Care - Consent Forms*