I am the biological parent/legal guardian of the above listed child and give the following people of legal age (18+) listed below authorization to bring my child to Hamilton Mill Pediatrics for medical care, including any neccessary treatments and consent for vaccinations. This statement will remain in effect until I give written notice of any changes.
**please note that you are required to inform us in writting of any legal/custody issues regarding your child so we may add it to the chart**
Thank you,