For families who have established relationships with our practice, it may be convenient to have on file prior authorization for medical care for children when a parent cannot be present for treatment. This form authorizes EAR, NOSE, AND THROAT ASSOCIATES to provide medical care or treatment to a minor who is accompanied to an office visit by an adult who is not the minor's parent or legal guardian.
In my absence.
I understand that this consent may be revoked at any time in writing to EAR, NOSE, AND THROAT ASSOCIATES.
If the nature of the medical care is not routine or considered urgent, please contact me (us) regarding the healthcare of my child at the following phone numbers:
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.
Your browser does not support capabilities required for electronic signatures.