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*

End Date

Patient's Information

Patient's Name

First Last

Date of Birth

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

Guardian Information

Authorization

Information for Patients

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