Proxy Approval Form

Consent*
I give permission for Center City Pediatrics to sign me up as a "proxy" to access my child (ren)’s online health record.
Your Name*
First Last
Email*
Phone*
Proxy passcode (last four digits of your oldest child’s date of birth [YYYY])*
Name of child*
Date of birth*
MM slash DD slash YYYY
Do you have another child?*
- Yes
- No
Name of child*
Date of birth*
MM slash DD slash YYYY
Do you have another child?*
- Yes
- No
Name of child*
Date of birth*
MM slash DD slash YYYY
Do you have another child?*
- Yes
- No
Name of child*
Date of birth*
MM slash DD slash YYYY
Relationship*
- Mother
- Father
- Step Mother
- Step Father
- Guardian
- Other
Other*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please note that this information above will invite a proxy to join our patients' online health records. This information will NOT be updated or entered into your child (ren)'s account.
Preferred Provider
- Dr. Berger
- Dr. Warren
- Dr. Madani
- Dr. Fischer
- Dr. Barkan
- Dr. Robinson
- Dr. Chiang, D.O
- Dr. Rogers-McQuade
- Dr. DiBardino, D.O.
- Amanda Naumann, CRNP
- Jessica Rose, CRNP
Location*
- Center City (South Street)
- Bala Cynwyd
- Fishtown
Signature*