London Women's Care Pediatrics
Provide details to authorize an adult to accompany the minor for medical care, including consent and visit specifics.
Child/Patient Information
Full Name of Child/Patient
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Legal Guardian Information
Full Name of Parent/Legal Guardian
*
First Name
Last Name
Relationship to Child/Patient
*
Please Select
Mother
Father
Legal Guardian
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Parent/Legal Guardian Driver's License Number
*
Authorized Adult Information
The authorized adult must bring a photo ID each time they bring the minor to the visit.
Full Name of Authorized Adult
*
First Name
Last Name
Relationship to Child/Patient
*
Please Select
Grandparent
Aunt/Uncle
Family Friend
Other
Phone Number of Authorized Adult
*
Please enter a valid phone number.
Format: (000) 000-0000.
Full Name of Authorized Adult
*
First Name
Last Name
Relationship to Child/Patient
*
Please Select
Mother
Father
Legal Guardian
Grandparent
Aunt/Uncle
Family Friend
Other
Phone Number of Authorized Adult
*
Please enter a valid phone number.
Format: (000) 000-0000.
Visit Details and Limitations
Purpose of Visit(s) or Appointment(s)
*
Limitations or Special Instructions (if any)
Consent for Treatment and Disclosure
Authorization Effective Dates
Start Date
*
-
Month
-
Day
Year
Date
End Date
*
-
Month
-
Day
Year
Date
Parent/Legal Guardian Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Revocation or Update of Authorization
I hereby revoke or update this authorization as follows:
Submit Authorization
Submit Authorization
Should be Empty: