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 ________________________