Snake River
PEDIATRICS
Infants, Children, & Adolescents
1050 SW 3rd Ave, Suite 3200 • Ontario, OR 97914 • (541) 881-2380 • Fax (541)881-2389
Stephen Ames, MD, FAAP • Matthew Berria, PhD, PA-C • Sage Benintendi Stringer, MPAS, PA-C • Michelle DeVoe, DO, FAAP
Mary James, MPAS, PA-C • Chelsie Lewis, FNP-C • Kailey Meskill, MPAS, PA-C
CONSENT FOR TREATMENT
I voluntarily give my permission to the health care providers of Snake River Pediatrics, P.C. and such
assistants, as they may deem necessary, to provider medical services to my child. I also give my
permission for the following listed people to bring my child to Snake River Pediatrics, P.C. to obtain
medical care in my absence. I understand that by signing this form, I am authorizing them to treat my
child as long as I seek care from Snake River Pediatrics providers or until I withdraw my consent.
Name of Person(s) I give permission to bring my child in for medical care:
____________________________________________________________
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Patient name: ______________________________________________________________
Signature of Parent/Guardian: _________________________________________________
Printed name of Parent/Guardian: ______________________________________________
Relationship to patient: _______________________________________________________
I also give permission for the following people to bring my child in for immunizations.
Name of person(s) I give permission to bring my child in for immunizations:
____________________________________________________________
____________________________________________________________
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Signature of Parent/Guardian: __________________________________________________