Date account set-up Initials
Please list the name and date of birth of all children in your family.
Patient Name: ________________________________________________Date of Birth: __________________________
Patient Name: ________________________________________________Date of Birth: __________________________
Patient Name: ________________________________________________Date of Birth: __________________________
Patient Name: ________________________________________________Date of Birth: __________________________
Patient Name: ________________________________________________Date of Birth: __________________________
My Kids Chart - Patient Portal
Access to records is available for all children under 18 years of age. When a patient turns 14 years old in the State of Washington, by
law, their record automatically becomes private. They may grant permission to a parent or guardian to access their chart by signing
an additional release form.
Please list the name and email of the parent/guardian that would like access to the patient portal:
Parent/Guardian Name: _______________________________________________________
Email address: _______________________________________________________________
Authorization for Other Caregivers
The person listed below is designated as our agent to give consent (verbal or written) to surgical or medical treatment by any licensed
physician or provider at North Seattle Pediatrics for my minor child. Such consent may include but is not limited to, administration of
necessary anesthetics, medical treatment, test, X-ray examinations, transfusions, injections, immunizations or drugs and the
performing of whatever procedures may be deemed necessary or advisable.
It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is
given to provide the authority to consent thereto as our said agent and the above-named child’s attending physician, in the exercise
of their best judgement, may deem advisable. This authorization shall remain effective unless revoked in writing by the
undersigned.
The undersigned hereby authorize (person other than parent/guardian):
Name: _______________________________________________ Relationship to patient: ___________________________________
Name: _______________________________________________ Relationship to patient: ___________________________________
Name: _______________________________________________ Relationship to patient: ___________________________________
My signature below certifies that all of the above information is true and accurate.
____________________________________________________________________ _________________
Signature of parent/guardian – type your name for electronic signature Date
