Permission to treat a Minor: Hillside Family Medicine must receive permission from a child's parent or legal guardian before providing treatments for an injury or illness that is non-life threatening. This form gives us legal permission to treat your child in case you cannot accompany him/her to the clinic for treatment. If the party accompanying your child (baby-sitter, friend, relative, etc.) does not present this information the clinic will attempt to contact you to request permission to treat your child. If unable to reach you the appointment may be rescheduled. A parent/legal guardian is required to attend a minor's first visit.
Personal Health Information Release (PHI): This release is not required but if you would like someone other than yourself to have access to your medical records such as a spouse or parent, please complete this release. This release does have some restrictions, see form for details.
Please fill out the following forms if requested/relevant: