CONSENT TO TREAT MINOR CHILDREN

I, Steven Johnson, parent or legal guardian of Kathryn Faith Johnson, born

the 2 5 day of April, 2016 do hereby consent to any medical care and the administration of
anesthesia determined by a physician to be necessary for the welfare of

my child while said child is under the care of Joan Gladson or John Gladson of

307 East Bergamot, City of Queenscreek State of AZ 85140 and I am not reasonably
available by telephone to give consent.

This authorization is effective from the 10 day of J u l y , 2023 to

1 day of A u g u s t , 2023

_ _
Signature of Parent or Legal Guardian Date

_ _
Witness Signature Witness Name (please print)

This consent form should be taken with the child to the hospital or physician's office when the
child is taken for treatment. This additional information will assist in treatment if it can be
furnished with the consent but is not required.

Family Address 19055 SW Hardtner Shortcut, Hardtner, KS 67057

Parent/Guardian Telephone: 620 409-0027 Parent/Guardian Telephone: 620 931-7552

Last Tetanus: 12/04/2020

Allergies to drugs or foods: Bactrim, Fentanyl, sulfa

Child's Physician: DR Siddharthan Sivamurthy Phone: 316 962-3100

Insurance: VA Medical Policy #856-93-7714

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