CONSENT TO TREAT MINOR CHILDREN

I (We) ______________________________ and ______________________________ the

parent(s) and natural guardian(s) of ______________________________, born

the ___ day of _______________________, 20___ do hereby authorize Mrs. Alina Comanescu to

receive and send all documents referring to the medical assistance of the child.

A photocopy of this consent shall be considered as effective and valid as the original.

This authorization is effective from the ___ day of _______________________, 20___ to

___ day of _______________________, 20___

_____________________________________ __________________
Signature of Parent or Legal Guardian Date

______________________________ ______________________________

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