Permission Letter Form

I give permission for the following people to bring my child(ren) in to West Hills Children's Medical Group for treatment/physical.

Child(ren) Name:

DOB:

Add Child's Name and Date of Birth

People allowed to bring my child(ren) to West Hills Children's Medical Group:

Add new Name

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.

Parent Name/Signature:

Date:

Your information will be encrypted.