grahampediatrics.com-Nonparent Consent Form-English

GRAHAM PEDIATRICS OF WOODSTOCK
105 Mirramont Lake Drive, Woodstock. Ga 30189
Phone 770-485-9670, Fax 866-698-9350, www. grahampediatrics.com

NON-PARENT CONSENT FORM

We require the consent of a parent/legal guardian to provide medical care for patients under the age of 18 and when a parent/legal guardian is not present. I authorize Graham Pediatrics of Woodstock (GPOW) and its personnel to deliver routine medical care to my child(ren) listed below, this includes but is not limited to consent for necessary medications, vaccinations, and procedures. I understand that I can revoke this authorization for any or all of these individuals at any time.

Children covered by this consent (list full names and date of birth)

Name

First NameMiddle NameLast Name

DOB

Name

First NameMiddle NameLast Name

DOB

Name

First NameMiddle NameLast Name

DOB

I authorize the following individual(s) to bring in my children to their appointments:

Name

First NameLast Name

Relationship to my child

Name

First NameLast Name

Relationship to my child

Name & Signature of Parent/Legal Guardian

First NameLast Name

Date

APPOINTMENT POLICY

Our goal is to provide quality medical care in a timely manner and to serve your child’s medical needs. Graham Pediatrics of Woodstock prefers to work only by appointments to serve you better.

- For scheduled appointments: After 3 no shows/cancellations (less than 24 hours prior to your appointment), you have chosen to find another provider.

- For same-day appointments: After 3 no shows/cancellations (less than 2 hours prior to your appointment), you have chosen to find another provider.

-Rescheduled Appointments: After 5 consecutives short notice reschedule, you have chosen to find another provider

Please CALL our office:

If you need an appointment for an additional child prior to your arrival.
If you are late, we have a 15 minute grace period after your appointment time. Otherwise, we will have to reschedule your appointment.
If you need to reschedule your appointment, please call us 24 hours prior to your appointment.

Our office makes reminder calls for your appointment. This is done as courtesy to you. It is your responsibility to confirm and to attend to your appointment as scheduled.

Initials

Signature