Temporary Caretaker Permission Form

Temporary Caretaker Permission Form
Name of Temporary Caretaker*

First NameLast Name
Name of Temporary Caretaker

First NameLast Name
Name of Temporary Caretaker

First NameLast Name
Name of Temporary Caretaker

First NameLast Name
Dates the caretaker will be in charge of your child(rent) care*
Name of child covered by this agreement*
Name of child covered by this agreement
Name of child covered by this agreement
Name of child covered by this agreement
I give permission for physicians and staff from Saugatuck Pediatrics to evaluate, treat, and follow up with the above listed person(s) during the dates provided. Please check below as to what you give permission for:*

Scheduling AppointmentsMedication prescribingMedication Dispensing/purchasingRoutine Lab Results (excluding drug, pregnancy and STD testing)Concerns raised by caretaker
I understand that I am ultimately responsible for payment of my children(s) medical bills. I have read, reviewed, and acknowledge Saugatuck Pediatrics’ HIPAA and Financial policies.
Parent name*

First NameLast Name
Parent Email
example@example.com
Parent Signature*

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