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Center City: (215) 735-5600 Bala Cynwyd: (610) 257-9000 Fishtown: (215) 278-2500

Center City Pediatrics

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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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Bala Cynwyd

33 Rock Hill Rd
Suite 170
Bala Cynwyd, PA 19004
Call: (610) 257-9000
Fax: (484) 270-8133

Center City

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

Fishtown

2365 East York Street
Philadelphia, Pennsylvania 19125
Call: (215) 278-2500
Fax: (215) 644-9083

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