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*
CAPTCHA

Primary Sidebar

What To Do When The Office Is Closed

View Details

Contact Us

*Non-medical inquiries only

Name
Phone
Email
Message
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Footer

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

Footer

About

Recent Posts

Bala Cynwyd

Center City