Non-Parent/Guardian to Accompany Patient Authorization Preview Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Authorization - Non-ParenUGuardian to Accompany Patient Periodically there may be times when you are unable to bring your child to the office for an appointment and need to rely on a family member or friend. We understand these circumstances; however, we must have a written authorization letter allowing this person to accompany your child(ren). The person bringing your child will need to present a photo identification at the time of service. This authorization gives the person permission to bring your child(ren) in, speak to the doctor, authorize medication/treatment, and make general health decisions. Agreement:I, *FirstMiddleLast,give the person(s) listed below permission to bring my child to Children's Psychiatric Services of South Texas, and to discuss and share medical information about my child. I further authorize them to see all necessary medical records and make health care decisions of a routine nature as determined at the sole discretion of the CPSOST provider. I also give them authority to make more serious or urgent health care decisions in the event I cannot be reached or where it is of an emergency nature where there is not sufficient time to seek out my specific consent. Child's Name *FirstMiddleLastChild #1 Full NameDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #1 DOBAdd a second child? Yes Child's Name *FirstMiddleLastChild #2 Full NameDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #2 DOBAdd a third child? Yes Child's Name *FirstMiddleLastChild #3 Full NameDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #3 DOBLIST INDIVIDUALS ALLOWED TO BRING CHILD(ERN)IF ONLY PARENTS ARE ALLOWED TO BRING CHILD IN, PLEASE INDICATE 'NONE'Name of Person (allowed to bring child): *FirstLastRelationship: *Phone: *Add a second contact? Yes Name of Person (allowed to bring child) #2: *FirstLastRelationship: *Phone: *Add a third contact? Yes Name of Person (allowed to bring child) #3: *FirstLastRelationship: *Phone: *Electronic Signature Disclosure and Consent:Agree * I AGREE By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor. When I sign the document, I will receive a copy of this document via email. Signers Name *FirstMiddleLastSigners Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signers Phone Number *Submit
