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?*YesNoName of child*Date of birth* Date Format: MM slash DD slash YYYY Do you have another child?*YesNoName of child*Date of birth* Date Format: MM slash DD slash YYYY Do you have another child?*YesNoName of child*Date of birth* Date Format: MM slash DD slash YYYY Relationship*MotherFatherStep MotherStep FatherGuardianOtherOther*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. BergerDr. WarrenDr. MadaniDr. FischerDr. BarkanDr. RobinsonDr. LeeDr. Chiang, D.OAmanda Naumann, CRNPPaige Blumenthal, CRNPLocation*Main Office (Center City)Satellite Office (Bala Cynwyd)Signature*