Consent for Treatment Form

    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.
  • Completion of this section serves as a legal electronic signature
  • Date Format: MM slash DD slash YYYY
  • I give my permission for medical treatment for my son/daughter if an accident/illness should occur while he/she is a student at UALR. 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
  • Date Format: MM slash DD slash YYYY