Non-Parent/Guardian to Accompany Patient Authorization

Non-Parent/Guardian to Accompany Patient Authorization

This form must be completed before having a non-parent/guardian accompany your child to their appointment.
Periodically there may be times when you are unable to bring your child to the office for an appointment and need to rely on a family member or friend. We understand these circumstances; however, we must have a written authorization letter allowing this person to accompany your child(ren). The person bringing your child will need to present a photo identification at time of service.

This authorization gives the person permission to bring your child(ren) in, speak to the doctor, given authorization for treatment, vaccinations, medication, certain procedures and make general health decisions.
I parent/guardian full name, give the person(s) listed below permission to bring my child to Quest Center for Integrative Health and to discuss and share medical information about my child. I further authorize them to see all necessary medical records and make health care decisions of a routine nature as determined at the sole discretion of the Quest Center provider.

I also give them authority to make more serious or urgent health care decisions in the event I cannot be reached or where it is of an emergent nature where there is not sufficient time to seek out my specific consent.
Child's name:
Date of Birth:
Child's name:
Date of Birth:
Child's name:
Date of Birth:
Name of Person (allowed to bring child):
Relationship:
Example: family friend/ uncle, grandparent, babysitter
Name of Person (allowed to bring child):
Relationship:
Example: family friend/ uncle, grandparent, babysitter
Name of Person (allowed to bring child):
Relationship:
Example: family friend/ uncle, grandparent, babysitter
I certify that the above information is true and accurate:*

Clear
Parent/Guardian Signature
Please provide an email address if you would like a copy for your records:
example@example.com
Should be Empty: