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Clinical Pediatric Associates of North Texas Elizabeth S. Dickey MD PhD FAAP Mary A. Brown MD FAAP Trung D. Tran MD FAAP Minor s Name Consent to Treatment of a Minor 7200 N State Hwy 161 Suite 100 Irving TX 75039 2011 Northwest Hwy. Suite 160 Grapevine TX 76051 Date of Birth I the undersigned attest that I am the custodial parent or legal guardian of the above-referenced Minor the minor and hereby authorize Clinical Pediatric Associates of North Texas to administer treatment as it so deems...
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