Child Covid-19 Testing Authorization

Parent/Legal Guardian Name:

Relationship to Child:

To the J&K Healthy Choice and its affiliates

I GIVE CONSENT for the child named at the top of this form to get a COVID-19 Test and reviewed and agree to the information

First Name:*

Last Name:*

Child’s Date of Birth:

Age:

Address:

City:

Zip:

Country:*

State:

Province:*

Phone Number:*

I am an emancipated or self-sufficient minor or married or previously married

If you check this box, you may be asked to attest to this

Signature of Parent/Legal Guardian:

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