Patient / Guardian Consent Form — Atlantis Pediatric Hospital

I, the undersigned, hereby consent to and authorize the physicians, nurses, and other healthcare professionals at Atlantis Pediatric Hospital to perform the following as may be deemed necessary for the medical care and treatment of the patient named herein:

• Routine medical examinations and diagnostic procedures
• Administration of medications and treatments
• Laboratory and imaging investigations
• Minor procedures as clinically indicated

Emergency Treatment: In the event of an emergency where I am unable to be reached, I authorize the hospital to administer emergency medical treatment as deemed necessary by the attending physician to preserve life and prevent serious harm.

Confidentiality: I understand that my personal and medical information will be kept strictly confidential and used solely for the purpose of providing healthcare services, in accordance with applicable Nigerian Health Laws and the hospital's privacy policy.

Information Sharing: I consent to the sharing of relevant medical information with other treating physicians or specialists involved in my/the patient's care, as necessary for continuity of care.

Photography / Documentation: I understand that clinical photographs or recordings may occasionally be taken for medical documentation purposes only, with my prior consent sought separately.

Financial Responsibility: I accept responsibility for all charges incurred for services rendered. I understand that non-payment may affect future services.

Right to Withdraw: I understand that I retain the right to withdraw consent at any time, though doing so may affect the quality of care that can be provided.

By signing below, I confirm that I have read, understood, and voluntarily agree to the terms of this consent. If signing on behalf of a minor or incapacitated patient, I confirm that I am the legal parent or guardian.