MEDICAL AUTHORIZATION FORM (CHILD)

This form is to be used to authorize other adults over 18 years of age to bring your child to this practice and to seek treatment. Please complete one form for each child you wish covered by this authorization.

I,(Parent name), give permission for the individuals listed below to bring my child, (Child's First Name / Middle Name / Last Name) (Date of Birth), for office visits and to make medical decisions for my child, including signing for any immunizations.

Parent/guardian Name:

Childs First Name:

Middle Name:

Last Name:

Date of Birth:

Initial:

I understand that any authorized person will be required to pay any necessary copay, and is responsible to identify himself/herself to the staff as an authorized person upon arrival to the practice. They will need to have proof of identification.

Initial:

I understand that if I choose to have my co-pay billed to me there will be an additional $15 billing fee added to the cost.

Add another

PLEASE SELECT ONE:

Authorization is for all future visits or until I request this authorization be removed Authorization in effect for the following dates

If Authorization in effect for the following dates is selected, please specify the dates:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Parent/Guardian Name:

Signature:

Date:

Your information will be encrypted.