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2. Instructions (please fill out online, print, collect the necessary signatures and bring to the child's appointment)

   This form allows you to designate a person (other than yourself) 18 years of age or older to bring your child to the Immunization, Physical or TB appointment; stay during treatment; sign consent for treatment and related forms; including a medical history form as needed.  This form must be signed by you AND the person you designate as a proxy prior to the child's appointment.  

   PLEASE NOTE: Step-parents must be designated as a proxy unless there is legal documentation of guardianship

4. Child's First Name*
5. Child's Last Name*
7. Child's Date of Birth*
9. Name of Legal Parent or Guardian (PLEASE PRINT)*

   I, (parent or legal guardian), give my permission for my Designated person or persons to be present during appointment, and to consent for all treatment to be performed.)

11. Name of Designated Person 1*
13. Signature of Designated Person 1 (please sign in black or blue ink)
15. Name of Designated Person 2
17. Signature of Designated Person 2 (please sign in black or blue ink)
19. Proof of Understanding

    I understand that this permission form must be in my child's record before treatment can be provided without a parent or legal guardian present. Proxy forms are valid for the current appointment only.

21. Parent/Legal Guardian Signature and Date

    Please sign in black or blue ink.

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22. Print Only

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