Adult Consent

Adult Consent

If patient is 18 years or older
Date*

MonthDayYear
Date
Patient Name*
DOB*
In my absence, I hereby give authorization for the person(s) to have any and all access to my medical records on file with Chisholm Trail Pediatrics.
Authorized persons
Relationship to patient
Authorized persons
Relationship to patient
Authorized persons
Relationship to patient
Authorized persons
Relationship to patient
Patient Printed Name
Patient Signature

Clear
Should be Empty: