I, the undersigned parent or legal guardian, attest that I am the lawful guardian of the minor child(ren) listed below and authorize Fast Access Healthcare, PLLC to provide medical services to said minor(s) under the Direct Primary Care Membership Agreement.

I understand that pediatric membership is available only to children five (5) years of age or older.

I accept full financial responsibility for all membership fees and additional fees associated with the below listed minor(s).

I acknowledge that no refunds will be issued.