Designation Form

1. I,

am the Parent or Legal Custodian/Guardian of:

Childs name

whose Date of Birth is

And I have the power to make medical decisions for my child.

2. There is no court orders that limits my parental authority or that prohibits me from making this designation.

3. By signing below, I authorize the following person(s) whom are listed in the box(es) below, who are over the age of eighteen, to act as designee(s).

4. This designation is good for ONE YEAR from the date of signature below unless revoked by court order. This designation can only be revoked by a court order.

Designees have the authority to:

Schedule, reschedule, or cancel appointments

Attend office visits and give/receive health information (verbally and printed)

Discuss health information over the phone

Consent for treatment during office visits

Sign for authorization to administer immunizations and vaccines

Pick up paperwork and samples

Designees do NOT have the authority to:

Request medical record transcripts or transfer care to a different practice
Activate a patient portal for the child listed above
Perform any other action or assume any rights that parents or legal custodian/ guardians are afforded

Contact information of Parent(s) or Legal Custodian(s)/Guardian(s) and the Designee(s) (listed below only) During the period of this designation

Parent or Legal Custodian/Guardian

Address

Phone

Parent or Legal Custodian/Guardian

Address

Phone

Add Additional Designee

5. The person(s) I designate on this form will be able to perform functions outlined above except:

List any exceptions

This designation is good for ONE YEAR from the date of signature below unless revoked by court order.

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 or Legal Custodian/Guardian Signature:

Date

Parent or Legal Custodian/Guardian Name (PRINT):

Date

This authorization is only valid at Summerwood Pediatrics.

Revised 7/22/20, 9/29/15, 6/29/23, 1/26/24, 9/10/24

Your information will be encrypted.