Consent for Evaluation and Treatment
I, the undersigned parent or legal guardian, hereby give consent for my minor child to receive evaluation and treatment at Sol Medical Clinic.
I acknowledge that the scope of practice of this clinic is limited to musculoskeletal injuries. I understand that Sol Medical Clinic is not a pediatric clinic and does not provide general pediatric or primary care services. The providers are not pediatricians and will only be evaluating and treating the minor for injuries specifically related to the presenting accident. If any unrelated or broader pediatric concerns arise, I understand that I should also be promptly seen by a pediatrician or family practice physician to provide a complete evaluation.
I understand that treatment may include, but is not limited to, medical evaluation, diagnostic procedures (e.g., x-rays), physical therapy, and other non-surgical interventions related to injury care.
I authorize the caregiver to request, obtain, review, and inspect any and all information bearing upon my dependent’s health and relevant to any such decisions.
I acknowledge that:
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I am authorized to provide consent for medical care and treatment of the minor listed above.
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The medical providers at Sol Medical Clinic will explain all proposed treatments and answer any questions I may have.
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I have the right to refuse or discontinue treatment at any time.
Emergency Care
In the event of a medical emergency, I authorize the staff at Sol Medical Clinic to initiate appropriate emergency medical treatment and/or transport my child to the nearest emergency facility, if needed.
I acknowledge that I am responsible for all reasonable charges in connection with the care and treatment rendered to my dependent during this period.
