Medical Proxy

PROXY PERMISSION FORM

PATIENTS WHO ARE NOT ACCOMPANIED BY A PARENT OR GUARDIAN

A parent or legal guardian must accompany all children/teens under the age of 18. The parent or guardian can designate another person to seek medical care for their minor by completing this required form.

I, (Please input Name below) give the following person(s) permission to make medical decisions and to sign any appropriate documents related to my child(ren), (Please input child(ren) below) in my absence.

(Parent/Guardian)

(child(ren))

Name:

Relationship:

Add new row

For minor patients of driving age:

(parent/Guardian)

Give my child(ren),

(parent/Guardian)

permission to seek medical treatment by themselves without a parent/legal guardian in accompaniment. I acknowledge that my child is of driving age and has the ability and maturity to understand our medical recommendations.

Signature

(Parent/Guardian)

Date

Print Name

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