Patient Name :
Chart Number :
Address :
Phone :
Date of Birth:
By signing below, I do hereby state that in my absence, the persons listed below may accompany my minor child listed above to any and all office visits at Rocky Mount Family Medical Center. I understand that the persons will be expected to present identification at each visit and remain in the room at all times during the visit. By signing this statement, I also agree to give the listed personas access to my child's medical and financial information, and permission to make medical decisions as needed. This document may be revoked by the parent/legal guardian at any time by providing Rocky Mount Family Medical Center with the request to revoke in writing. The persons listed below must be 18 years of age or older and must present a valid government issued ID at the time of the visit.
This Consent Will be effective as of the date of the signature and will expire::
Name :
Relationship :
Parent/ Legal Guardian Printed Name :
Date: