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I give my consent for CENTC to discuss patient's medical care and payment for medical care with the following people:
Patients read and sign agreement
In the case of divorced parents or shared custody arrangements, the court specifies the healthcare responsibilities for the child and boundaries of the involved parties. If the patient is a child of divorced parents or shared custody, please answer the following questions based on the court document that specifies the child's healthcare needs.
According to the decree, which parent may consent to treatment and coordination of healthcare needs (not surgical)
According to the decree, which parent may give consent for surgical procedures (invasive procedures)
IMPORTANT NOTE: On all initial consultations, the legal parent or guardian MUST BE PRESENT
Please state who may bring the child in for follow-up other than the legal parent or guardian?
THIS CONSENT REMAINS IN PLACE UNTIL REVOKED IN WRITING OR CHILD IS NO LONGER A MINOR
3705 Medical Parkway
Austin, Texas 78705
601 Leah Avenue
San Marcos, Texas 78666
Phone (512) 324-2720
Fax (512) 324-2721