Parental Consent

							                                                Parental Consent

                                     “Care for Your Child While You’re Away”

Patient’s Name: _____________________________________                          Birth date: ________________


I, ________________________________________________________________________________________,
                                                      (Parent/Guardian)

Of __________________________                    ____________________________          ____________________
          (City)                                              (County)                           (State)



Grant permission for the Physicians of Pediatric Associates of Southern Indiana to provide medical care as
deemed medically necessary to the above-named dependent while being cared for by the following caregivers
who are at least 21 years of age.

    Authorized Persons Name                  Relationship to child        Birth date     Date this form expires




  If someone who is not authorized should bring your child, please send a written note with that
          person. If we have no authorization complete services may not be rendered.




_______________________________________________________                     _______________________________
                   Parent/Legal Guardian Signature                                      Date