Proxy for Treatment "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Proxy for TreatmentPlease select your HFM location: (REQUIRED)* Clayton Four Oaks Riverwood Patient:Patient Name:Date of Birth:Thank you for entrusting the care of your child to our practice. To provide the beset quality of care for your child we require that the parent or legal guardian accompany the child to appointments. We realize that your child may need to be seen for an acute sick visit and the parent or legal guardian may be unable to be present or minor capable of driving presents by him or herself. By completing the information below we will be able to meet the needs of your child during your absence.Authorized Person(s):In the absence of the parent or legal guardian, I give the person(s) listed below permission to seek medical care and treatment for my child. I also realize that the person listed below may have access to pertinent protected health information if medically necessary. These individuals will be asked to present identification at the time of the visit. If someone other than these persons listed below beings in your child, we will attempt to contact the parent or legal guardian for verbal permission to treat. Name of Authorized Person (1):Date of Birth (1):Relationship to Patient (1):Contact Number (1):Name of Authorized Person (2):Date of Birth (2):Relationship to Patient (2):Contact Number (2):Name of Authorized Person (3):Date of Birth (3):Relationship to Patient (3):Contact Number (3):Name of Authorized Person (4):Date of Birth (4):Relationship to Patient (4):Contact Number (4):Name of Authorized Person (5):Date of Birth (5):Relationship to Patient (5):Contact Number (5): For patients 16 years and older ONLY:The patient listed above may present and be treated unaccompanied by an adult/parent/legal guardian: Yes No Please be sure the person accompanying your child has all the pertinent information regarding your child’s illness/care in order to provide the highest quality of care. Signature of Parent/Legal Guardian:Your NameYour NameYour NameYour NameRelationship:Date:Parent(s) or Legal Guardian(s) Contact Information: Name (1):Relationship(1):Home Number (1):Cell Number (1):Work Number (1): Name (2):Relationship (2):Home Number (2):Cell Number (2):Work Number (2): Who does patient live with: Mom Dad Both Parents Other Other:(If other, please provide legal proof of living arrangement for minor patient, including any custody/legal information.)
