You are hereby notified pursuant to Michigan Law that as a patient of this practice your child may be tested for the presence of HIV or an HIV antibody without your consent if any health professional or other health facility employee sustains a percutaneous membrane open wound exposure to your child's blood or other body fluids. This test is permitted by Michigan Law and is for the protection of your child as well as the protection of the physicians and employees of Muskegon Pediatrics.

I, the parent/guardian named below, give permission for these Authorized Persons to bring my child/children, the patients named below, to Muskegon Pediatrics when I am unable to attend.

I, the parent/guardian named below, authorize the release and/or sharing of information about the Patient named below, with the following persons or entities listed below ("Authorized Caregivers").

Muskegon Pediatrics participates with the national Carequality registry. This registry allows hospitals and physicians across the country to exchange information regarding your health, such as current medications, most recent weight, height, blood pressure, and allergies. This exchange of information allows your child to receive better and informed care if he/she would need to visit an emergency room or see another physician.

If you would NOT like to have this information available, please provide this in writing to Muskegon Pediatrics. 

I acknowledge that I was given this information.