We understand that it's not always possible for mom or dad to bring a patient to the office for treatment. This authorization form provides guardian consent needed to treat a child under 18 years of age. Please print, complete, and return the form to us via fax, mail, or in person.
If you are 18 years or older and would like to give permission for other adults to have access to your medical records, please complete this form. You may fax the completed form to our office or drop it off at the office. Please carefully read each segment of this form and sign it.
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