I have the legal right to consent for medical treatment for the patient.

 
 
 

As I am unable to be present during this appointment, I authorize the following responsible adult,

to bring the patient to their appointment and give consent for medical care. I understand such medical care may include treatments deemed medically necessary by the providers at Mississippi Pediatric Endocrine Care. I authorize this person to also receive confidential health information about the patient which may include test results, diagnosis, treatment plan, and follow-up instructions. I understand it is my responsibility to discuss the information given with this person and that I may contact MSPEC with any questions I may have. I understand it remains my responsibility to follow through with the treatment plan, patient instructions, and recommended follow-up despite the fact I was not present during the appointment.