Authorization to Provide Information to Child Care Provider or School Health Officer

authschool
Authorization to Provide Information to Child Care Provider or School Health Officer
Patient Name*
Date of Birth*

MonthDayYear
Date
I give authorization for Dr. Atiga's staff to provide any information (written or verbal) regarding services rendered to my child care provider or school health office upon their request.
Please specify any restriction:*
School Name*
School Phone Number*
Please enter a valid phone number.
School Fax #*
Legal Guardian Signature

Clear
Relationship to the patient?
Printed Name of Parent/Guardian*
Date*

MonthDayYear
Date
Upload Parent/Guardian Driver's License or ID*

Cancelof
Should be Empty:

authschool