Authorization to Provide Information to Child Care Provider or School Health Officer

authschool
Authorization to Provide Information to Child Care Provider or School Health Officer
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I give authorization for Dr. Atiga's staff to provide any information (written or verbal) regarding services rendered to my child care provider or school health office upon their request.
Please specify any restriction:
School Name
School Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
School Fax #
Legal Guardian Signature
Relationship to the patient?
Printed Name of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload Parent/Guardian Driver's License or ID

Cancelof
Should be Empty:

authschool