Authorization for Other Caregivers

Authorization for Other Caregivers

Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patients

List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?
Patient 1 Name*
Patient 1 Date of Birth*

MonthDayYear
Date
Patient 2 Name
Patient 2 Date of Birth

MonthDayYear
Date
Patient 3 Name
Patient 3 Date of Birth

MonthDayYear
Date
Patient 4 Name
Patient 4 Date of Birth

MonthDayYear
Date
Patient 5 Name
Patient 5 Date of Birth

MonthDayYear
Date
Patient 6 Name
Patient 6 Date of Birth

MonthDayYear
Date
Authorization for Caregivers Other Than Parent or Guardian

The people listed below are designated as our agent to give consent (verbal or written) to surgical or medical treatment by any licensed physician or provider at Essex Pediatrics for my minor child, and to receive relevant protected health information. Such consent may include but is not limited to, administration of necessary anesthetics, medical treatment, test, X-ray examinations, transfusions, injections, immunizations or drugs and the performing of whatever procedures may be deemed necessary or advisable.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide the authority to consent thereto as our said agent and the above-named child’s attending physician, in the exercise of their best judgement, may deem advisable. This authorization shall remain effective unless revoked in writing by the undersigned.
Caregiver 1 Name*

First NameLast Name
Relationship to Patient*
Caregiver 2 Name

First NameLast Name
Relationship to Patient
Caregiver 3 Name

First NameLast Name
Relationship to Patient
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Authorization for Other Caregivers

Patients

Authorization for Caregivers Other Than Parent or Guardian