Pediatric Practices of Northeastern Pennsylvania

   Medical Treatment Authorization

I,                                                                                                    ,  the parent and/or legal guardian of
                       

                                                                           ____________________  hereby authorize
                    (Patient Name)                                       (Date of Birth)

                                                                    ____________________________________to
                          (Name/Address of person accompanying child)

accompany my above-named child to office visits with Pediatric Practices of Northeastern Pennsylvania and to consent to the examination, diagnostic testing, immunization, and/or treatment of my child during office visits.

This authorization:

             is effective only on                         , 20        .

             is effective from                            , 20          to                     , 20         .

             is effective until revoked by me in writing.

I reserve the right to revoke this authorization at any time in writing to
Pediatric Practices of Northeastern Pennsylvania.

                                                                                                                                                
 SIGNATURE  (Parent/Guardian)                                                           DATE

                                                                                                                                                 
WITNESS SIGNATURE                                                                       DATE