PACGPA On-site Check-in
Check-in Time (Hora de entrada)
AM
PM
Please fill out all fields and one of our team members will call you shortly. (Complete todos los campos y uno de los miembros de nuestro equipo lo llamará en breve.)
Are you a New Patient or Current Patient? (¿Eres un paciente nuevo o un paciente actual?)
New Patient
Established
Patient Name
Date of Birth
Consent To Treat (Consentimiento para tratar):
In presenting my son/daughter (or as legal guardian for the above noted individual) for diagnosis and treatment, I thereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment, by authorized members of the Pediatric and Adolescent Center of Grand Prairie & Arlington staff or their designees, as may in their professional judgment be necessary. I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition.We/I acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered.
Al presentar a mi hijo / hija (o como tutor legal de la persona mencionada anteriormente) para el diagnóstico y el tratamiento, de manera voluntaria doy mi consentimiento para la prestación de dicha atención, incluidos procedimientos de diagnóstico, tratamiento quirúrgico y médico, por miembros autorizados de Pediatría y Adolescencia. El personal del Centro de Grand Prairie & Arlington o sus designados, según sea necesario a su juicio profesional. Reconozco que no se me han otorgado garantías sobre el efecto de dichos exámenes o tratamiento en la condición de mi hijo. Nosotros / nosotros reconocemos que somos (soy) responsables de todos los cargos razonables relacionados con la atención y el tratamiento prestados.
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