New Patient Packet Page 2

HIPAA RELEASE OF MEDICAL INFORMATION

Please list all persons that may have access to your child’s medical information.

Example: appointments, prescription pick up, general medical information, lab results or

medical emergencies.

If their name and phone number is not on the list, they will not be allowed to have any

information on the patient. Please make sure to update any changes at each appointment.

CHILD’S NAME:

__________________________________________________

DATE OF BIRTH: ___________________________

GUARDIAN SIGNATURE:

______________________________________________

DATE:

___________________________

Name

Phone Number

Relationship

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Parent category: Medical