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Authorization for Treatment
Email
*
Please provide your contact email for this request.
Name
*
First
Last
Relationship to Child
*
I authorize Metropolitan Pediatrics to allow the individial named above to:
view and hear private health information
make treatment decisions for my child
Start Date
*
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Patient's Information
Patient's Name
First
Last
Date of Birth
MM slash DD slash YYYY
Guardian Information
Name
First
Last
Relationship to patient:
*
Parent
Legal Guardian
Self
Authorization
By submitting this form I authorize the person mentioned in this form may bring child / children for care and treatment at the office of Metropolitan Pediatrics.
I authorize the above
*
Agree
Signature / Initial
Information for Patients
Ages & Stages
Safety & Prevention
Expecting Parents
Health Issues
Information for Patients
