Permission to Treat

I (We) Print name(s) of legal guardian(s)* authorize Passaic Pediatrics, PA and its personnel to deliver medical services to my child(ren), listed below.
Full Name:
Date of Birth

MonthDayYear
MM/DD/YYYY
Email
example@example.com
Full Name:
Date of Birth

MonthDayYear
MM/DD/YYYY
Email
example@example.com
Full Name:
Date of Birth

MonthDayYear
MM/DD/YYYY
Email
example@example.com
Full Name:
Date of Birth

MonthDayYear
MM/DD/YYYY
Email
example@example.com
Full Name:
Date of Birth

MonthDayYear
MM/DD/YYYY
Email
example@example.com
Full Name:
Date of Birth

MonthDayYear
MM/DD/YYYY
Email
example@example.com
I (We) authorize the following people to bring my child(ren) in for treatment, and/or to contact in case of an emergency:
Full Name:
Phone:
Relationship:
Full Name:
Phone:
Relationship:
Full Name:
Phone:
Relationship:
Full Name:
Phone:
Relationship:
Print name of Legal Guardian(s)
Date

MonthDayYear
MM/DD/YYYY
Signature of Legal Guardian(s)
Relationship to patient
PrimaryPhone Number
Should be Empty: