Pediatric Practices of Northeastern Pennsylvania

1837 Fair Ave.
Honesdale, PA 18431

27B Woodlands Drive
Waymart, PA 18472
396 Routes 6 & 209
Milford, PA 18337
62 Industrial Park Road
Lake Ariel, PA 18436


Permission is granted to the physicians and employees of Pediatric Practices of Northeastern Pennsylvania to do such procedures as may be necessary to diagnose, treat, and care for the needs of myself (if 18 years old or older), or of my dependent minor child including but not limited to routine office and laboratory procedures such as strep tests and throat cultures, urine studies, complete blood counts (CBC), hematocrits, bladder catheterization, removal of cerumen (ear wax), removal of foreign bodies, drainage of abscess, fracture care, medication injections, and treatment of skin lesions, warts, burns, and lacerations.

Patient Name: _______________________________________  Date of Birth: ______________
                        (Please Print)

Signature of Custodial Parent or Guardian: ________________________________________

Date: _________________

This authorization shall remain effective until such time that it is revoked in writing and delivered to Pediatric Practices of Northeastern Pennsylvania.