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Permission for Third Party to Seek Treatment


We want our office to be as convenient for you as possible, but we also require documentation to ensure your child's safety and privacy.

This form is a guideline; you can modify if needed. We can put this in your child's file, or you can leave it with your child's temporary guardian 'just in case' they need a visit.

Remember to leave instructions for your child's regular medications, contact information for any places you may be staying, and a copy of your insurance card.

We especially recommend filling this form out if you are going to be out of town, if your parents or neighbors watch your children often, or if you have a nanny or regular caretaker.

We will need a separate form for each child. We will also request a copy of a photo ID from anyone who brings your child in; this will go in the child's permanent file.


PDFDownload Permission for Third Party to Seek Treatment Form