Under 18 Release of Information Form

PATIENT NAME:

I (insert name below) give permission for Bloomington Pediatrics, Ltd to release information to the following persons:

Name of Parent

NAME:

RELATIONSHIP:

PHONE NUMBER:

This consent will expire when the patient reaches 18 years of age. A new form must be completed by the patient at that time.

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.

Signature of parent:

Parent Phone Number:

Date:

Your information will be encrypted.