Communication Permissions
ABC Pediatrics • 5333 W. University Drive, McKinney, TX 75071 • (972) 569-9904
Patients
I give permission to ABC Pediatrics staff to communicate information regarding medical care and appointments relating to:
How many children in the family does this apply to?
*
Please Select
One
Two
Three
Four
Five
Six
Patient 1 Name
*
Patient 1 Date of Birth
*
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Month
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Day
Year
Date
Patient 2 Name
*
Patient 2 Date of Birth
*
/
Month
/
Day
Year
Date
Patient 3 Name
*
Patient 3 Date of Birth
*
/
Month
/
Day
Year
Date
Patient 4 Name
*
Patient 4 Date of Birth
*
/
Month
/
Day
Year
Date
Patient 5 Name
*
Patient 5 Date of Birth
*
/
Month
/
Day
Year
Date
Patient 6 Name
*
Patient 6 Date of Birth
*
/
Month
/
Day
Year
Date
Communication of Medical Information: Parent 1
The communication can be delivered by the following methods. Select all that are applicable.
Parent 1 Name
*
Contact Methods
*
Home Phone
Mobile Phone
Work Phone
Patient Portal
Home Phone
*
Please enter a valid phone number.
Can we leave a voice message?
*
Yes
No
Mobile Phone
*
Please enter a valid phone number.
Can we leave a voice message?
*
Yes
No
Work Phone
*
Please enter a valid phone number.
Can we leave a voice message?
*
Yes
No
Communication of Medical Information: Parent 2
The communication can be delivered by the following methods. Select all that are applicable.
Parent 2 Name
Contact Methods
Home Phone
Mobile Phone
Work Phone
Patient Portal
Home Phone
*
Please enter a valid phone number.
Can we leave a voice message?
*
Yes
No
Mobile Phone
*
Please enter a valid phone number.
Can we leave a voice message?
*
Yes
No
Work Phone
*
Please enter a valid phone number.
Can we leave a voice message?
*
Yes
No
Additional Caregivers
I give ABC Pediatrics permission to discuss with the following individual(s) listed below information reasonably deemed to be directly related to such child(ren) on the above referenced patients’ health care. Individuals listed below may also bring my child(ren) into ABC Pediatrics for treatment (examples: Grandparents, Relatives, Babysitters, Step-Parents, etc.)
Caregiver 1 Name
Caregiver 1 Phone
*
Please enter a valid phone number.
Relationship to Patient
*
Caregiver 2 Name
Caregiver 2 Phone
*
Please enter a valid phone number.
Relationship to Patient
*
Caregiver 3 Name
Caregiver 3 Phone
*
Please enter a valid phone number.
Relationship to Patient
*
Consent and Signature
I understand that I may change the above information at any time by sending my written request to my physician. Any change requested does not affect any communication previously made in reasonable reliance on this form.
Parent/Guardian Signature
*
Printed Name
*
Relationship to Patient
*
Date
*
/
Month
/
Day
Year
Date
Submit
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