MEDICAL DECISION AUTHORIZATION FORM

(INCLUDE ALL CHILDREN)

Patient name:

Date(s) of birth:

IF ONLY LEGAL GUARDIAN, MOTHER OR FATHER ARE AUTHORIZED, PLEASE SELECT YES.

NO YES

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):

Name:

Relation to child/children:

Exceptions to decision making:

Add new row

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.

Name of parent/legal guardian:

Date:

Your information will be encrypted.