Permission for Physicians to Discuss Medical Information For patients 18 years and over

Please correct the errors described below.

Over the age of 18 your doctor is not allowed to discuss medical issues with your parents unless you agree. We will clear any discussion with you in advance. You are in control of which information we discuss. Be assured that any information which has been confidential in the past, will remain so.

I understand this authorization may be revoked by me at any time by notifying Burgess Pediatrics in writing. 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.

Your information will be encrypted.