Except for life threatening emergencies, we are not able to treat your minor child unless he or she is accompanied to our office by a parent, legal guardian or a designated adult.

In order to designate an adult to bring your child into our office for medical care in your absence, you must have the following form(s) completed, signed and on file for each designated adult for each of your children.

Minor children reporting for an appointment without a parent, legal guardian, an adult named in a signed designee form or a signed note from a parent may need to be rescheduled.

I attest that the above named individual(s) is/are 18 years of age or older as of this date. I authorize the above named individual(s) to consent to treatment for my child(ren). This may include, but, is not limited to, consent for necessary medications, vaccinations, procedures and hospitalization. Glendale Pediatrics may relay any medical information about my child necessary for the above named individual(s) to provide informed consent to the treatment.

I understand that the doctor will communicate his or her findings and treatment plan to the caregiver who brings in the child, and that under most circumstances, a follow-up call to me personally should not be necessary.

I agree to hold Glendale Pediatrics and its staff harmless for any disagreement between the above named individual(s) and myself regarding treatment decisions.

I attest that I am the parent or legal guardian of the following children and that I have the legal authority to make this agreement. I understand that I can revoke this authorization for any or all of these individuals at any time.