I, {{GuardianName}}, am the parent or legal guardian of {{ChildName}} (“Child”), born {{Date}}, and hereby give my consent for Reliant.MD to provide medical care and treatment to the Child, including any diagnostic procedures and tests that the physicians, his or her associates, assistants or other health care providers determine to be necessary or advisable in their professional judgment. In the course of the Child’s treatment, I understand and acknowledge that no warranty or guaranty has been or will be made as to any result, care, or treatment. I consent to the taking of photographs or screen shots related to the care and treatment of the Child, and understand that such photographs or screen shots may be made part of the Child’s medical record and/or used for internal purposes, such as performance improvement or education. This consent for evaluation and treatment shall be valid for any and all medical conditions in which Reliant.MD provides services for the Child through the MDBox mobile application. This consent shall remain in full force and effect from today’s date to the earlier of: a) the date on which the Child turns eighteen (18), or b) the date I provide Reliant.MD notice in writing of my withdrawal of this consent.
Further, I voluntarily authorize E-Prescribing for the Child’s prescriptions, which allows health care providers to electronically transmit prescriptions to the pharmacy of my or the Child’s choice, review pharmacy benefit information and review medication dispensing history for as long as a physician/patient relationship exists.
I acknowledge that I am responsible for all reasonable charges in connection with the care and treatment rendered to the Child during the period of this consent.
I have read, understand, and give my consent as stipulated above.
I have read, understand, and give my consent to the Reliant.MD Informed Consent for Evaluation and Treatment Informed Consent on behalf of the Child.