Parent Questionnaire

Child Immunization and Treatment Policies

Pediatric Health Associates expects a parent/legal guardian to accompany their child to each and every office visit. In the event that this is not possible, then a written release must be provided to PHA including the following:

1) Date the release is written

2) Child's name

3) Child's date of birth

4) Parent/legal guardian signature

5) Phone number where parent/legal guardian can be reached in case of an emergency

6) Person authorized to accompany your child and make medical decisions in the event that a parent/legal guardian cannot be contacted. Please note this person's relationship to the parent and child.

This is only effective for one date of service. Please note that immunizations/allergy shots will only be given in the presence of the parent/legal guardian. Any other requests outside these guidelines must be approved in writing by our nursing manager.

Authorization for Treatment of a Minor