Chaperone list

Ball Pediatrics

3619 Braselton Hwy Suite 103 PHONE 770-513-8882 FAX 770-513-3545
AUTHORIZED CHAPERONES
Date*

MonthDayYear
Child's name*

First NameLast Name
Patients date of birth*

MonthDayYear
Date
Name of Person Completing Form*

First NameLast Name
Relationship to Patient*
Phone Number*
Please enter a valid phone number. By providing my contact information, I acknowledge and give my explicit consent to be contacted via SMS. Message and data rates may apply. Message frequency may vary. Reply STOP to opt out
Email
example@example.com
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 Ball 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,
Name

First NameLast Name
Relationship to Patient
Name

First NameLast Name
Relationship to Patient
Name

First NameLast Name
Relationship to Patient
Name

First NameLast Name
Relationship to Patient
Name

First NameLast Name
Relationship to Patient
Any other restrictions we should know about?
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