Name: Pediatric People
Price range: $

Patient Information

Patient Name*

First Last

Patient Date of Birth*

Parent or Legal Guardian Information

Parent or Legal Guardian Name*

First Last

Relationship to Patient*

Will you allow someone (besides you or the child's other parent) to bring your child to Pediatric People, PLLC for medical treatment?*

Yes, I authorize Pediatric People, PLLC to provide medical treatment to my child without my presence.

The individuals listed below are authorized to bring my child to Pediatric People, PLLC for medical treatment.

By signing this document, I acknowledge I have read and agree to this consent and that any questions I had prior to signing were answered by Pediatric People, PLLC.

Authorized Individual 1*

First Last

Authorized Individual 2

First Last

Authorized Individual 3

First Last

Authorized Individual 4

First Last

Signature of Parent or Legal Guardian*

Date of Signature*