PARENTAL RELEASE (IF PATIENT IS A MINOR)

(legal guardian's name)
hereby authorize Gainesville Pediatric Associates, Inc. and its physicians to release any or all patient health information including confidential information regarding my child to the person(s) listed below (Example: A relative or someone other than a legal guardian may accompany your child on a future appointment).
MM slash DD slash YYYY

PATIENT RELEASE (18 YEARS OR OLDER)

(patients name)
hereby authorize Gainesville Pediatric Associates and its physicians to release any or all of my patient health information including confidential information to the person(s) listed below. (Example: A parent or relative may be involved in medication, billing, and insurance inquiries.
MM slash DD slash YYYY