JUST FOR KIDS PEDIATRICS, PLLC

AUTHORIZATION FOR NON-PARENT TO CONSENT TO CARE

I am the legal guardian/ parent of:

Patient’s Full Name

Date of Birth:

I authorize the following persons to seek medical care for the above listed child(ren) and they must present their ID at every visit:

Add another person

This authorization permits the above-named persons to consent for the following:

Medical care

Labs

Vaccinations

Antibiotic injections

Prescriptions

This authorization will remain in force until revoked in writing by me. I hereby attest that I have the legal authority to delegate my authority to consent for care, and that no legal agreement prevents me from delegating authority.

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 Signature:

Date:

Printed Name:

Your information will be encrypted.