Grant/Decline Permission to Share Information ages 18+
Patient's Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian'sName
First Name
Last Name
Parent/Guardian'sName
First Name
Last Name
GRANT permission
I GRANT permission for Bay Street Pediatrics to DISCUSS my medical information with the Parent(s)/Guardian(s) listed above
I GRANT permission for Bay Street Pediatrics to give access to my medical PORTAL to the Parent(s)/Guardian(s) listed above
DECLINE permission
I DENY permission for Bay Street Pediatrics to DISCUSS my medical information with the Parent(s)/Guardian(s) listed above
I DENY permission for Bay Street Pediatrics to give access to my medical PORTAL to the Parent(s)/Guardian(s) listed above
Patient's Signature
Submit
Should be Empty: