Consent from Parents or
Guardians for Authorized Persons
As the parent or guardian of
_______________________________, I am granting permission for the below listed
person(s) to bring my child in for treatment and/or care.
PLEASE
SELECT ONE OF THE FOLLOWING CHOICES:
- I
am granting full permissions, meaning the below listed person(s) will be
allowed to agree to treatments, and know all health history pertaining to
my child. _____ Initials.
- I
am granting permissions, meaning the below listed person(s) is only
allowed to bring my child in, and will have access to all health history,
but not allowed to agree to treatments without my direct consent. _____ Initials.
- I
am granting limited permissions, meaning the below listed person(s) is
allowed to bring my child in to the office, but is not allowed access to
any medical information or treatment of my child. I will be informed of the visit results,
and I will be notified prior to any treatment for my child. _____ Initials.
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________________________________
Parent/Guardian Signature Date
_______________________________________________________
Witness Signature Date