Patient Form Submission4. Consent for TreatmentPlease complete all applicable fields. An asterisk (*) indicates a required field. Name * First Name Last Name Date of birth * MM DD YYYY Consent for treatment * By signing this consent, I am authorizing my physician(s) and/or order another person to perform all exams, tests, procedures, injections, phlebotomy, and any other care deemed necessary or advisable forthe diagnosis and treatment of my medical condition. This consent is valid for each visit I make to Dr. Meskill with Tricoastal Narcolepsy and Sleep Disorders Center unless revoked by me in writing. I recognizing that typing my initials below constitutes my electronic signature. Who signed the form * Self Spouse Parent Guardian Reason someone other than the patient signed If someone other than the patient signed this form, please indicate why in the field below: Thank you!