Authorization for Medical Care to Minors Online Form

Please correct the errors described below.

I,

, the parent or legal guardian of the minor(s) listed below:

Do hereby authorize medical treatment by Kid Approved Pediatrics, PLLC

Name of the adult person(s) authorized to bring minor child in for medical treatment.

Telephone number(s) where parent or guardian can be reached.

By printing your name in the signature box, this is confirmation of e-signature.

Your message will be encrypted and can only be read by Kid Approved Pediatrics.