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*
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Patient's Information
Patient's Name
First Last
Date of Birth
Date Format: 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