I hereby authorize and consent to an x-ray, examination, anesthesia, medical, surgical, or dental diagnosis or treatment and hospital care to be rendered under the general or specific supervision and on the advise of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. *I also authorize (if I so provide it) the administration of my child's prescribed epinephrine auto injector.