Unless a court has stated otherwise (and a formal legal document can be provided to us), the parents listed on the birth certificate are the only people allowed to approve medical care being provided to you a child. If a parent or LEGAL guardian isn’t bringing the child to his/her appointment, then we need permission from the parent that we can see that child. Please complete the following information to authorize us to see your child with the following people you would like to be able to bring your child to appointments.
I, the parent/guardian, give the physicians and clinical staff permission to examine, instill drops and administer necessary tests to the following patient(s) without my presence. I swear that that the information below is correct, and that I am the parent/legal guardian of the below-mentioned patients.