Grant/Deny Permission to Share Information ages 18 +

Grant/Decline Permission to Share Information ages 18+
Patient's Name

First NameLast Name
Date

MonthDayYear
Date
Parent/Guardian'sName

First NameLast Name
Parent/Guardian'sName

First NameLast Name
I GRANT permission for Bay Street Pediatrics to DISCUSS my medical information with the Parent(s)/Guardian(s) listed aboveI GRANT permission for Bay Street Pediatrics to give access to my medical PORTAL to the Parent(s)/Guardian(s) listed above
I DENY permission for Bay Street Pediatrics to DISCUSS my medical information with the Parent(s)/Guardian(s) listed aboveI DENY permission for Bay Street Pediatrics to give access to my medical PORTAL to the Parent(s)/Guardian(s) listed above
Patient's Signature

Clear
Should be Empty:

Grant/Decline Permission to Share Information ages 18+