Authorization to Accompany Minor to Appointment

I authorize the following individual(s) to accompany my child to his/hers doctor’s appointment(s) and further allow Brickyard Pediatrics to verbally disclose and discuss medical information about my childs visit with:

Print Name:

Relationship to Patient:

Print Name:

Relationship to Patient:

This consent is valid for 1 year from date of signature unless I notify you in writing of my withdrawal:

Patient Name:

Patient Date of Birth:

Parent/Legal Guardians Name Printed:

Parent/Legal Guardians Signature:

Date:

Your information will be encrypted.