Permission to Accompany and Treat a Minor Without the Presence of a Parent/Guardian

Permission to Accompany and Treat a Minor Without the Presence of a Parent/Guardian
This form gives consent for someone other than yourself to accompany a minor child to Greater Cleveland Pediatrics for medical care. You may choose to have this form in effect for a specific visit or it may be used indefinitely (unless you make changes/revoke). You only need to complete this once per family; make sure to list all children to be covered by this form below. Except in emergencies, Greater Cleveland Pediatrics cannot, by law, provide medical care to your child(ren) or accept medical consent to treat your child from another individual without you explicit written permission.
Name of patient #1 under age 18 years:*

First NameLast Name
Date of birth of patient #1:*

MonthDayYear
Date
Name of patient #2 under age 18 years:

First NameLast Name
Date of birth of patient #2:

MonthDayYear
Date
Name of patient #3 under age 18 years:

First NameLast Name
Date of birth of patient #3:

MonthDayYear
Date
Name of patient #4 under age 18 years:

First NameLast Name
Date of birth of patient #4:

MonthDayYear
Date
Phone number of Parent/Guardian (which may be used to call parent at the time of the visit):
Please enter a valid phone number.
Alternative phone number of Parent/Guardian (if not available at above number):
Please enter a valid phone number.
Parent/Guardian Authorization (please check all):*

I authorize, and have the legal right to authorize, Greater Cleveland Pediatrics to deliver routine medical care to my child(ren) listed above as deemed necessary by the physician for the diagnosis and/or treatment of my child. I understand that routine medical care may include, but is not limited to: medical evaluation, physician exam, standard testing associated with my child's diagnosis or medical evaluation (such as blood draws, throat cultures, urinalysis, nasal swabs for influenza testing, x-rays), procedures (such as wart and molluscum treatment, splinting of suspected fractures, suturing of injuries), and administration of standard childhood immunizations.I understand that I will be responsible for the payment for any testing performed which is not included in my membership with Greater Cleveland Pediatrics.I understand that a parent/guardian must be available by phone at the time of visit
Please indicate any specific limitations regarding the type of medical services you authorize. If none, please state "none".
Please list name, relationship to patient, and phone number of all individuals whom you are granting permission to accompany your child to medical visits. *
For patients who are 16 or 17 years old (check only one) ONLY:

I give my child permission to be seen by him/herself.I do NOT give my child permission to be seen by him/herself
This consent is in effect:

For the following date (entered below) ONLYIndefinitely, until revoked in writing
Single date consent effective:

MonthDayYear
Date. Please leave blank if consent is to be used indefinitely.
Name of parent/guardian providing consent: *

First NameLast Name
Relationship to patient: *
Date:*

MonthDayYear
Date
Signature of parent/guardian:*

Clear
Should be Empty: