Authorized Pick Up Person
Date
Parent Name
*
First Name
Last Name
Patient Name
*
First Name
Last Name
Alternate Pick Up Person Name
*
First Name
Last Name
When will the alternate be permitted to pick up?
*
Please Select
Only this one time
They are authorized moving forward - any time.
how long is this in effect?
Driver's License Number (To be Verified by Staff Upon Pick Up)
*
Please note relationship or other considerations:
Signature of Parent or Verifying Staff
Submit
Should be Empty: