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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
*
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
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