Authorization for Treatment

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

Email(Required)

Please provide your contact email for this request.

Name(Required)

First Last

Name of person bringing the child.

Relationship to Child(Required)

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(Required)

End Date

Patient's Information

Patient's Name

First Last

Date of Birth

Guardian Information

Name

First Last

Relationship to patient:(Required)

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(Required)

Agree

Signature / Initial