THOMAS R. BODENSTINE, M.D.
BRADLEY J. WASSERMAN, M.D.
TINA B. STEWART, M.D.
MARY-CASSIE SHAW, M.D.
ANGELICA L. SWIERSZ, M.D.
Oberlin Road Pediatrics
CONSENT BY PROXY FOR NON-URGENT PEDIATRIC CARE
(For families who are ongoing patients of Oberlin Road Pediatrics)
I appoint, _____________________________________________________________________________, who is my
(Name)
(Address)
child(ren)'s ______________________________________________________________ as my proxy decision maker
(Specify Nature of Proxy's Relationship to the Children)
for consenting to non-urgent medical care for my children listed below. I have the legal right to delegate such
consent to the proxy decision maker, who is an adult and legally and medically competent to exercise the authority
so delegated. Be advised that protected patient health information may be shared with the proxy to facilitate
informed decision making.
Name: __________________________________
DOB: _______________
Name: __________________________________
DOB: _______________
Name: __________________________________
DOB: _______________
Name: __________________________________
DOB: _______________
LIMITATIONS
Identify any limitations on the kinds of medical services for which this consent by proxy is given. If none, state
"none.
_____________________________________________________________________________________
_____________________________________________________________________________________
Identify any limitations on the time frame for which this consent by proxy is given. If none, state "none."
_____________________________________________________________________________________
_____________________________________________________________________________________
CONTACT INFORMATION
If the nature of the medical care is not routine, please try to contact me regarding the health care of my children at
the following telephone number(s). If you are unable for any reason to contact me, you may rely on the proxy
decision maker for consent.
Parent's Name:
_______________________________
Parent's Name:
_____________________________
Daytime phone: _______________________________
Daytime Phone: _____________________________
Evening Phone:
_______________________________
Evening Phone:
_____________________________
Cell Phone:
_______________________________
Cell Phone:
_____________________________
IN WITNESS WHEREOF, the undersigned have executed this instrument as of the ____ day of ____________200__.
________________________________________
_________________________________________
Parent or Legal Guardian
Parent or Legal Guardian
________________________________________
Proxy Decision Maker
Telephone: 919-828-4747
Fax: 919-828-6765