Authorization to Release Health Information

Consent For Non-Parent to Bring Minor Child to Appointment
I am the parent or guardian of the below listed child/children. I have the legal rights to consent to medical treatment for the patient(s).

Patient(s) registered at Peak Pediatric Care*

I authorize the following individual, who is a person(s) over 18 years of age, to bring the patient(s) to medical appointments and to consent to medical treatment deemed necessary by the providers and medical staff at Peak Pediatric Care at the time of the appointment. I understand this delegation includes receiving information about the minor(s) which is necessary to make immediately necessary health care decisions.
Person #1 bringing patient(s) to appointment*
Relationship to patient(s)*
Person #2 bringing patient(s) to appointment
Relationship to patient(s)
This consent is valid until revoked in writing by me, the parent or legal guardian.
Signature*

Clear
Date*

MonthDayYear
Date
Your Full Name*
Phone Number*
Should be Empty:

Consent For Non-Parent to Bring Minor Child to Appointment