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MARTIN PEDIATRIC & ADOLESCENT CLINIC AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION Please print Patient Another Last Names Date of birthstone NumberEmail Address Street Addressing, State,
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Martin Pediatric & Adolescent is a medical clinic specializing in the healthcare of children and teenagers.
Parents or legal guardians of pediatric and adolescent patients are required to file forms at the clinic.
Forms can be filled out online through the clinic's website or in person at the clinic.
The purpose of the forms is to provide necessary information for the medical treatment and care of pediatric and adolescent patients.
Information such as patient's medical history, allergies, current medications, and contact information must be reported on the forms.
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