Skip to content
6440 W. Newberry Road, Suite 402, Gainesville, FL 32605 - Phone:
(352) 333-5500
- Fax: (352) 333-5506
Search for:
HOME
Meet Our Team
Pediatrics After Hours
Patient Forms
COPE Program
Contact Us
Patient Release
Patient Release
gnvpa
2023-01-16T03:28:35-05:00
PARENTAL RELEASE (IF PATIENT IS A MINOR)
I,
(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).
Signature
Reset signature
Signature locked. Reset to sign again
Date
MM slash DD slash YYYY
First Name
Last Name
Email
Relationship to Patient
First Name
Last Name
Email
Relationship to Patient
First Name
Last Name
Email
Relationship to Patient
PATIENT RELEASE (18 YEARS OR OLDER)
I,
(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.
Signature
Reset signature
Signature locked. Reset to sign again
Date
MM slash DD slash YYYY
First Name
Last Name
Email
Relationship to Patient
First Name
Last Name
Email
Relationship to Patient
First Name
Last Name
Email
Relationship to Patient
Page load link
Go to Top
