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*
Date Format: MM slash DD slash YYYY
Do you have another child?*
- Yes
- No
Name of child*
Date of birth*
Date Format: MM slash DD slash YYYY
Do you have another child?*
- Yes
- No
Name of child*
Date of birth*
Date Format: MM slash DD slash YYYY
Do you have another child?*
- Yes
- No
Name of child*
Date of birth*
Date Format: 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. Lee
- Dr. Chiang, D.O
- Amanda Naumann, CRNP
- Paige Blumenthal, CRNP
Location*
- Main Office (Center City)
- Satellite Office (Bala Cynwyd)
Signature*

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Message
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This field is for validation purposes and should be left unchanged.

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About

Center City Pediatrics offers patients and their families access to pediatric care through friendly phone and email access and convenient office hours. Center City Pediatrics is a recognized Patient-Centered Medical Home by the NCQA.

Bala Cynwyd

33 Rock Hill Rd
Suite 170
Bala Cynwyd, PA 19004
Call: (610) 257-9000
Fax: (215) 735-5690

Center City

1740 South Street
Suite 200
Philadelphia, PA 19146
Call: (215) 735-5600
Fax: (215) 735-5690

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