Permission Form To Bring A Child

Permission Form

Permission Form to authorize another person to bring a minor to APC Pediatrics. If this is not applicable, you may skip to the next section.
This form is to grant permission for the following person to bring the child to any of our APC Pediatrics locations to obtain medical treatment when I'm not available:*

Approved Persons First NameApproved Persons Last Name
What is the person above relationship to the patient?*
Grandmother, Uncle, etc
Patient Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
If at any time this adult/person above is no longer allowed to bring the patient into the office, it is the parent's responsibility to inform our office in writing that a parent is withdrawing this authorization.
Parent Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Parent Signature*

Clear
Should be Empty: