I give permission for my child to be medically evaluated and treated at New Smyrna Wellness Center in my absence. I understand that it may be necessary to perform diagnostic tests (for example, a throat culture or blood tests) in the course of evaluation. I accept responsibility for physician and laboratory fees.
This consent applies to:
1.Complete physician check-up (including blood and urine samples)
2.Hearing, vision, scoliosis, and blood pressure screening
3.Immunizations
4.First aid and emergency care
5.Prescription and treatment for illness
6.Referrals to outside agency (for example: hospital, radiology) for services not provided at this office.