Info for Parents
Letter to Parents
Parent and Patient Expectations
Immunization Policy Update
Locations and Directions
Latest News
Suggested Reading
Our Care Team
Patient Portal
Appointments
Schedule an Appointment
Routine Checkup and Immunization Schedule
Prenatal Visits
Quick Sick Hour
Forms
Contact Us
Info for Parents
Letter to Parents
Parent and Patient Expectations
Immunization Policy Update
Locations and Directions
Latest News
Suggested Reading
Our Care Team
Patient Portal
Appointments
Schedule an Appointment
Routine Checkup and Immunization Schedule
Prenatal Visits
Quick Sick Hour
Forms
Contact Us
Disclosures
Disclosures to Family Members and Friends
I,
, the parent/legal of the following child/children:
Understand that disclosures may be made to family and friends related to the patient's health or as needed for payment for health care services. I understand that only information relevant to current treatment will be disclosed. I agree that health information can be disclosed to the following people: (please include individuals who may be calling our office, bringing the child in for treatment, picking up forms, etc. This might include stepparents, grandparents, babysitters, aunts/uncles, or family friends.)
Name
Relationship
Phone#
Initials
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