Consent by Proxy for Minor (Permission to Treat Form) - Arizona Allergy Associates

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Practice Limited to Allergy, Asthma & Immunology
Adult and Pediatric
CONSENT BY PROXY FOR MINOR (Permission to Treat Form)
I, Printed Name of Parent/Guardian, __________________________________________________ authorize
Name of Proxy: ______________________________________ Relationship to Minor(s) __________________
Address: _______________________________ ______ __________ as proxy decision maker for consenting to
routine medical care for my child(ren) listed below. Additionally, protected patient health information may
be shared with the proxy to facilitate informed decision making.
Child’s Name: ______________________________________
DOB: __________________________
Child’s Name: ______________________________________
DOB: _________________________
Limitation
Identify any limitations on the kinds of medical serves for proxy cannot consent. If none, state “none”.
______________________________________________________________________________________________
This authorization is valid for six (6) months from the date of signing and may be revoked at any time
providing written notice of revocation. I understand I cannot revoke this authorization retroactively for
treatment already provided.
I understand that instructions or information given to Responsible Party bringing in patient for visit,
treatment, medication(s) will be the only information given and parent will not be called separately with
information from this office. I understand that Responsible Party must be 18 years or older.
I authorize my underage child/patient (16 or 17) to bring themselves in for treatment and they have the
ability to understand the risks and benefits of treatment.
If the nature of the medical care is not routine, please try to contact me at the following telephone numbers.
If you are unable to contact me, you may rely on the proxy decision maker for consent.
Signature of Parent/Guardian: _________________________________ Date: ___________________________
Telephone Number(s): _______________________ ________________________ ________________________
705 S. Dobson Rd.
8140 E. Cactus Rd., Ste 710
4852 E. Baseline Rd, Ste 101
348 E. Virginia Ave.
Chandler, AZ 85224-5657
Scottsdale, AZ 85260-5265
Mesa, AZ 85206-4604
Phoenix, AZ 85004-1208
Phone: 480.897-6992
Phone:
480.344.4460
Phone:
480.346.4680
Phone:
602.266.4114
Fax:
480.752.1757
Fax:
480.344.4465
Fax:
480.346.4685
Fax:
602.274.5225
www.azallergy.com
Practice Limited to Allergy, Asthma & Immunology
Adult and Pediatric
CONSENT BY PROXY FOR MINOR (Permission to Treat Form)
I, Printed Name of Parent/Guardian, __________________________________________________ authorize
Name of Proxy: ______________________________________ Relationship to Minor(s) __________________
Address: _______________________________ ______ __________ as proxy decision maker for consenting to
routine medical care for my child(ren) listed below. Additionally, protected patient health information may
be shared with the proxy to facilitate informed decision making.
Child’s Name: ______________________________________
DOB: __________________________
Child’s Name: ______________________________________
DOB: _________________________
Limitation
Identify any limitations on the kinds of medical serves for proxy cannot consent. If none, state “none”.
______________________________________________________________________________________________
This authorization is valid for six (6) months from the date of signing and may be revoked at any time
providing written notice of revocation. I understand I cannot revoke this authorization retroactively for
treatment already provided.
I understand that instructions or information given to Responsible Party bringing in patient for visit,
treatment, medication(s) will be the only information given and parent will not be called separately with
information from this office. I understand that Responsible Party must be 18 years or older.
I authorize my underage child/patient (16 or 17) to bring themselves in for treatment and they have the
ability to understand the risks and benefits of treatment.
If the nature of the medical care is not routine, please try to contact me at the following telephone numbers.
If you are unable to contact me, you may rely on the proxy decision maker for consent.
Signature of Parent/Guardian: _________________________________ Date: ___________________________
Telephone Number(s): _______________________ ________________________ ________________________
705 S. Dobson Rd.
8140 E. Cactus Rd., Ste 710
4852 E. Baseline Rd, Ste 101
348 E. Virginia Ave.
Chandler, AZ 85224-5657
Scottsdale, AZ 85260-5265
Mesa, AZ 85206-4604
Phoenix, AZ 85004-1208
Phone: 480.897-6992
Phone:
480.344.4460
Phone:
480.346.4680
Phone:
602.266.4114
Fax:
480.752.1757
Fax:
480.344.4465
Fax:
480.346.4685
Fax:
602.274.5225
www.azallergy.com

Download Consent by Proxy for Minor (Permission to Treat Form) - Arizona Allergy Associates

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