Consent to Treat

I hereby authorize the physicians and employees of Arbor Pediatrics to render medical evaluations and care to the patient 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 patient or legal guardian. 

Consent for Release of Medical Information

I hereby authorize the release and discussion of my private medical information including results of examinations, tests, procedures, treatments and any other aspects of my medical care with the following people. (For example, if you would like your parents to be able to schedule an appointment for you or discuss any of your medical care with us, they would need to be listed below.)

My Kid's Chart Patient Portal Communication

I authorize Arbor Pediatrics to communicate my 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 (include yourself)

 

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, Consent for Release of Medical Information, 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 patient