Kyle D. Parish, M.D., PSC

1532 Lone Oak Road, Suite 305

Paducah, KY 42003

Phone: 270-443-0010 Fax: 270-538-5622

______________________________________________________________________________

Consent for Treatment of Minor

Parental and/or legal guardian permission for medical examination and treatment by the office of Kyle D. Parish, M.D., PSC

Patient Name: ______________________________________________________________________

Last First Middle

Date of Birth ___________________________ Social Security Number ________________________

List two persons to be notified in case of emergency. One should be a parent or legal guardian.

1. _____________________________________ 2. __________________________________

Business Phone __________________________ Business Phone _______________________

Home Phone ____________________________ Home Phone _________________________

PARENTAL PERMISSION

The following consent should be signed by the parent or legal guardian of minors so that appropriate diagnosis and treatment may be given, and so that no unnecessary delays will occur with emergency operative procedures. No operation will be performed, except in an emergency, without a parent or legal guardian being contacted and fully informed if reasonably possible.

I give permission for my son/daughter ____________________________________________________

to receive necessary medical treatment at the office of Kyle D. Parish, M.D., PSC. I understand that any medical care has risks and benefits, but that these cannot be fully described here in anticipation of a potential for treatment.

Signature __________________________________________ Date ___________________________

Relationship to Patient _______________________________ Witness ________________________