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  _________________________






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  ________________________