Arbor Authorization/Consent to Treat a Minor

AUTHORIZATIONS and CONSENTS for MINORS
Consent to Treat Minor

I hereby authorize the physicians and employees of Arbor Pediatrics to render medical evaluations and care to the patients listed below. I understand that this authorization is given in advance of any specific diagnosis or treatment being required. This authorization will remain in effect until revoked in writing by the parent or legal guardian.
Consent for Medical Treatment Authorization

I hereby authorize the following people to bring my child(ren) listed below to appointments at Arbor Pediatrics. I authorize them to consent to any and all examinations, test, procedures and treatments deemed necessary by the provider. In addition, the providers may discuss diagnosis or treatments with the authorized person(s) below.
Name of Authorized Person
Full Name
Relationship to child(ren)
Name of Authorized Person
Full Name
Relationship to child(ren)
Name of Authorized Person
Full Name
Relationship to child(ren)

My Kid's Chart Patient Portal Communication

I authorize Arbor Pediatrics to communicate my child(ren)'s health information with me through a secure patient portal system, My Kid's Chart. I give permission to Arbor Pediatrics to grant patient portal access to the follow individuals (parent or legal guardians only)
Portal User 1
Full Name
Relationship to child(ren)
Cell Number
Portal User 2
Full Name
Relationship to child(ren)
Cell Number
Portal Access for Adolescents

At Arbor Pediatrics, we encourage adolescents to take a more active role in their own healthcare. Through the patient portal, they will be able to complete pre-visit questionnaires and access medical information such as immunization records and visit history. If you would like to grant permission for your adolescent to have patient portal access, please complete the following.
Patient Name
Patient Cell Number
Number for portal registration

Automated Messages, Calls & Texts

I authorize Arbor Pediatrics to deliver the following types of messages by voice call or text messaging using automatic telephone dialing system or a prerecorded voice: appointment reminders, visit recalls, situational/seasonal service suggestions (ie. flu clinic) and balance due reminders
Agreement

I have reviewed and agree to the Consent to Treat Minor, Consent for Medical Treatment Authorization, My Kid's Chart Patient Portal Communication, and Automated Messages and Calls guidelines as stated above. This authorization will remain in effect until revoked in writing and applies to the following child(ren):
How many children are you registering?
Patient Name
Date of Birth

MonthDayYear
Patient Name
Date of Birth

MonthDayYear
Patient Name
Date of Birth

MonthDayYear
Patient Name
Date of Birth

MonthDayYear
Signature of Parent/Legal Guardian*

Clear
Name of Parent/Legal Guardian*
Today's Date

MonthDayYear
Should be Empty: