Permission to Speak to Parent/Guardian
Ages 18 and older
Patient Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
I AUTHORIZE the providers and staff permission to speak to the following Parents/Guardians regarding my medical care.
First Name
Last Name
First Name
Last Name
Signature
Clear
I REVOKE the providers and staff permission to speak to the following Parents/Guardians regarding my medical care.
First Name
Last Name
First Name
Last Name
Signature
Clear
Patient's Cell Number
*
-
Area Code
Phone Number
Patient's Email Address
*
example@example.com
Submit
Should be Empty:
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