Peds in a Pod Pediatrics, LLC
Biological Parent/Legal Guardian Information:
Proxy(s) Information (Step-Parent, Grandparent, Anyone Over the Age of 18):
I understand that upon providing ID, only the above-named proxy(s) shall be authorized to accompany my child to Peds In A Pod Pediatrics, LLC, consent to medical care, sign, and pick up forms/prescriptions.
Please note that due to the nature of some appointments and the need for a thorough history, a parent/legal guardian may need to be present. Please verify with our staff when making appointments whether a medical proxy is appropriate.
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.
Your information will be encrypted.