Authorization for Child to Be Brought for Pediatric Care by Family Member Other Than Parent/Legal Guardian
Authorize designated family members to bring your child for pediatric care at KAE Cubs Pediatrics. Please fill out all relevant information.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
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Month
-
Day
Year
Date
Parent/Legal Guardian
*
First Name
Last Name
Parent/Legal Guardian's Relationship to Child
*
Authorized Family Members
*
Authorization Statement: I hereby authorize the above-listed family member(s) to bring my child to KAE Cubs Pediatrics and to consent to pediatric care on my behalf. I understand that this authorization remains in effect until revoked in writing.
Parent/Legal Guardian Signature
*
Date Signed
*
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Month
-
Day
Year
Date
Submit Authorization
Submit Authorization
Should be Empty: