18 Year Old Parental Consent for Health Information
For parent, family member or young adult
Today's Date
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Month
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Day
Year
Young Adult Name
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Young Adult DOB
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Month
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Day
Year
Young Adult Contact #
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Young Adult Email
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Names of the individuals you would like to grant access
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If this option is selected DON'T select anything in the next selection below
I elect NO ONE to access ANY of my medical records or portal
Specific Access: (Please check one or more below)
Access patient portal & all medical records
Access only to patient portal
Authorize Referral Request
Authorize RX or sample pickup
Immunization Record
Pick up or email of medical records
Schedule, cancel, or reschedule appt
Test and/or lab results from triage nurse or provider
Other
Young Adult Signature
*
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Submit
3701 Eldorado Parkway, Suite 100, Mckinney, TX 75070 | P:972-548-7888 | F: 972-562-1170 | www.phamckinney.com
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