Authorization for Treatment

Please fill out the form below for Authorization of Treatment to treat minors in absence of parents / guardians

Email*

Please provide your contact email for this request.
Name*
First Last
Name of person bringing the child.
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

Patient's Information