Patient Consent Form

Medical Care Permission Form

Dear Parent(s)/Legal Guardian(s),

In case of emergency or because of unforeseen circumstances parent(s) or guardian(s) cannot always be present at office visits for illness or well-child exams. In stating this, one must realize medical decisions must still be made; therefore, Waterboro Village Pediatrics is requiring you to provide us with a list of additional people who you would delegate authority to make medical decisions for your child in your absence. Medical decisions may include, but not limited to, diagnostic tests and procedures, administration of medications including required and recommended vaccinations. It is your responsibility for you to make your intentions clear to whoever you delegate authority to in regards to your child’s medical care.

I hereby give permission to the following people to authorize medical care at the time of visit for my child or to be contacted in an event of an emergency:

If for some reason one of the persons listed above is unable to bring your child in or you send your older child in alone for an office visit, please send a note giving permission to seek medical treatment and authorize medical decisions. Please include any specific information and/or requests which would be helpful for WaterboroVillage Pediatrics staff in providing the best care for your child.

By signing this form, I understand this consent form is valid for 1 year and will need to be completed again upon expiration.