MEDICAL DECISION AUTHORIZATION FORM

Please correct the errors described below.

(INCLUDE ALL CHILDREN)

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By signing this medical decision authorization form, I am stating that I am the parent and/or guardian for the above named patients and am legally responsible for making any and all decisions regarding their medical care. I also authorize the following people to bring my children in to the office of Reis Pediatrics for medical care and to make medical decisions in my absence (please note any exceptions):

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I also authorize the people I have listed to pick up any medical records/forms on my behalf.

ID CARD WILL BE REQUIRED.

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.

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