Consent to Medical Examination

I,(Required)

(client/resident, parent or authorized representative)

do hereby consent to a physical examnination of(Required)

(client/resident)

by a physician designated by the California Department of Social Services and also consent to any laboratory tests associated with the medical examination for the purpose of investigating the possible abuse or neglect of(Required)

(client/resident)

Date:(Required)

Signature of Authorizing Person:(Required)

Relationship to client/resident -- if other than client/resident:(Required)

Address:(Required)

Street Address City State ZIP Code

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Consent to Medical Examination

San Diego

Sacramento

North Park

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