Authorization to Accompany & Consent for Treatment

5757 Monclova Road Suite 10, Maumee OH 43537

Phone: 419-887-0803 | Fax: 419-887-0817

Authorization to Accompany & Consent for Treatment

Please complete one form per patient. Return to the front desk.

Important — Minor Patient Policy

All patients under the age of 18 must be accompanied by a parent or legal guardian, or by an adult (18 years of age or older) who has been designated and authorized by the parent or legal guardian on this form. Monclova Road Pediatrics reserves the right to decline to see a minor patient who arrives without an authorized adult present.

Patient Information

Patient's Full Name (Last, First, MI)

Date of Birth

Age

Primary Insurance

Parent / Legal Guardian Information

Parent / Guardian Full Name

Relationship to Patient

Primary Phone

Secondary Phone

Email Address

Authorized Adults — Persons Permitted to Accompany Patient

Please list all adults (age 18 or older) who are authorized to bring your child to appointments and, if you choose, to consent to routine medical treatment on your behalf when you are unavailable. This authorization does not extend to surgical procedures, non-emergency hospitalization, or experimental treatment without direct parent/guardian consent.

Authorized Person 1

Full Name

Relationship to Patient

Phone Number

May this person consent to routine medical treatment on your behalf?

YesNo — accompany only

Any limitations or special instructions for this person:

Authorized Person 2

Full Name

Relationship to Patient

Phone Number

May this person consent to routine medical treatment on your behalf?

YesNo — accompany only

Any limitations or special instructions for this person:

Authorized Person 3

Full Name

Relationship to Patient

Phone Number

May this person consent to routine medical treatment on your behalf?

YesNo — accompany only

Any limitations or special instructions for this person:

Additional authorized persons (attach a separate sheet if needed):

Persons NOT Authorized to Accompany or Receive Information

If there are specific individuals who should NOT be permitted to bring your child to appointments, pick up your child, or receive any information about your child's care (e.g., due to a custody order or restraining order), please list them below. Attach a copy of any applicable court order.

Person 1

Full Name

Relationship to Patient

Reason / Court Order on File?

Person 2

Full Name

Relationship to Patient

Reason / Court Order on File?

Emergency Medical Consent

In the event of a medical emergency and I (the parent/guardian) cannot be reached, I authorize Monclova Road Pediatrics and/or emergency medical personnel to provide necessary emergency medical treatment for my child. I understand that every reasonable effort will be made to contact me before any treatment is administered.

Emergency Contact Name (if different from above)

Relationship to Patient

Emergency Contact Phone

Custody & Legal Notes

Is there a custody order or court order affecting who may bring this child to appointments?

Yes — copy attachedNo

Additional notes regarding custody, legal guardianship, or access restrictions:

Parent / Legal Guardian Signature

By signing below, I confirm that the information provided on this form is accurate and complete. I authorize the individuals listed above to accompany my child to appointments at Monclova Road Pediatrics and, where indicated, to consent to routine medical treatment on my behalf. I understand that this authorization remains in effect until I provide written notice of revocation to the practice.

Printed Name of Parent / Legal Guardian

Signature of Parent / Legal Guardian

Relationship to Patient

Date

Staff Witness Signature

Date Received

Please return the completed form to the front desk. Thank you for choosing Monclova Road Pediatrics!