About Hours and LocationMake an AppointmentMeet the StaffFormsGrievance Procedures Services Our ServicesMake an AppointmentEligibility & General InformationClinic ChargesWomen's Health CareSexual HealthSexually Transmitted Infection Testing & TreatmentRespiratory IllnessesNarcan Dispensers Name(Required) First Last UA Little Rock ID #(Required)Consent(Required) I have read the consent for treatment as shown below 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) First Last Completion of this section serves as a legal electronic signatureDate(Required) MM slash DD slash YYYY Signature of parent or guardian (if the student is under age 18) First Last 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 signatureDate MM slash DD slash YYYY Captcha
