Dan R. Baker, MD

1 Chisholm Trail, Suite 4100

Round Rock, TX 78681

Phone: 512/310-0900 Fax: 512/310-0318

PARENTAL CONSENT FORM (OPTIONAL)

(PATIENTS UNDER 18 YEARS OLD)

Patient Name: ________________________________________________________

Date of Birth: _________________________________________ Age: ___________

Parent/Guardian’s Name: ______________________________________________

I authorize my son/daughter to be treated by Dan R. Baker, M.D. or Brynn N. Clymer, FNP or their designee to provide my child with reasonable and proper medical care according to today’s standards without my presence. This authorizes my son/daughter to be seen:

*** ( ) today’s date of service: _________________,

*** ( ) any future dates for medical appointments, physicals, treatments

I do understand that it is my responsibility to schedule these appointments, and that I am financially obligated for these visits. I also understand that the staff is not responsible for any transportation issues or anything outside the consultation.

Signature: __________________________________________ Date: ________________

***Please be sure to specify your authorization for a specific visit or for any future visits. ***