I hereby authorize Dr. Weiner to care for the below mentioned minor:* and to administer whatever therapy he deems necessary or advisable in the diagnosis and treatment of this patient. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.Signature of Parent or Guardian Relationship Date* MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.