Proxy Approval Form 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*