Sometimes things happen…illness, work, life. We understand.
Please fill out the appropriate form(s) below if:
you need someone (18 years or older) other than yourself to bring your child(ren) into the office for a sick visit or injury.
you need someone to bring your child(ren) to the office for a routine physical that may or may not need vaccines.
Your child is 16 years - 17 years of age and will be attending their visit alone for a physical.
yOUR CHILD IS 16 YEARS - 17 YEARS OF AGE & BEING SEEN IN OFFICE ALONE FOR AN ACUTE SICK VISIT OR INJURY.
**Choose the appropriate form, download and sign before the scheduled appointment**.
Please have YOUR CHILD or PERSON who is accompanying your child(ren) bring this completed form to the office, or
email the completed form to Riverviewpediatric@gmail.com,
or fax to 315-592-3571 BEFORE the scheduled appointment.
Thank you,
River View Pediatrics