Hendersonville Consent to Communicate With Non Parent
It is Patient/Parent’s request that the practice communicate with a family representative on behalf of the parents/Guardians.
Name Patient 1
First Name
Last Name
Name Patient 2
First Name
Last Name
Name Patient 3
First Name
Last Name
Name Patient 4
First Name
Last Name
Name Patient 5
First Name
Last Name
Heading
The following person(s) may attend visits and receive information regarding: Check all that apply
Treatment scheduled to be performed.
Future treatment planned for the above named child or children.
Person Authorized 1
First Name
Last Name
Relationship
What is the relationship to you or the child?
Person Authorized 2
First Name
Last Name
Relationship
What is the relationship to you or the child?
Indicate when this authorization is valid for:
Only valid for the date below
One Time Authorization
Appointment Date:
-
Month
-
Day
Year
This authorization valid for any dates of service
All Future Authorizations
Parent or Legal Guardian:
*
First Name
Last Name
Email Address:
*
Signature
*
Submit
Should be Empty: