Authorization for the Treatment of a Minor
I authorize Proliance Surgeons Inc. (Puget Sound Ear, Nose & Throat Center) to treat the minor patient named here.
Authorization to Leave Personal Health Information by Alternate Means
Please provide information for all that apply.
With my signature below, I acknowledge and understand that this information will be kept in my medical record and these parameters will be abided by until revoked by me in writing. It is my responsibility to notify my healthcare provider should I change one or more of the telephone numbers provided here.