Consent for Treatment Form

Name(Required)
Consent(Required)
I hereby voluntarily consent to receive medical care (or for my minor child or ward under 18 years of age to receive medical care) from UA Little Rock Health Services. I also authorize such treatment and diagnostic studies as, in the judgment of the attending health care provider, may reasonably be necessary to preserve and protect my health (or the health of my minor child or ward). I have disclosed my medical history including any medication, drugs or alcohol I have taken. If you are under 18 years of age, your parent or guardian also must sign.
Patient Name(Required)
Completion of this section serves as a legal electronic signature
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Signature of parent or guardian (if the student is under age 18)
I give my permission for medical treatment for my son/daughter if an accident/illness should occur while he/she is a student at UA Little Rock. This includes referral to a local hospital which may result in his/her hospitalization, anesthesia, and surgery should it be necessary and I am unable to be reached. Completion of this section serves as a legal electronic signature
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