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Fiddle head Pediatric Healthcare 116 Narrow Gauge Square, Suite 101 Farmington, ME 04938 pH 2079560980 Fax 2079560981CONSENT BY PROXY FOR MONUMENT PEDIATRIC CARE FORM I appoint ___ (name) who lives
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How to fill out consent by proxy for

01
Obtain the necessary consent by proxy form from the relevant authority or organization.
02
Fill out the details of the proxy, including their name, relationship to the individual, and contact information.
03
Indicate the individual who is granting the proxy consent, along with their relevant details.
04
Specify the scope of the proxy's authority, outlining what decisions or actions they are authorized to make on behalf of the individual.
05
Sign and date the consent by proxy form, ensuring that all parties involved have reviewed and understood the terms of proxy consent.

Who needs consent by proxy for?

01
Consent by proxy is typically required for individuals who are unable to make decisions on their own behalf, either due to age, illness, disability, or other incapacitating circumstances.
02
This may include minors, individuals with cognitive impairments, elderly individuals with diminished capacity, or patients who are medically incapacitated.
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Consent by proxy allows someone to make decisions on behalf of another person.
Individuals who are unable to make decisions for themselves.
Fill out the form with the necessary information and have it signed by both parties.
The purpose is to ensure that decisions are made in the best interest of the individual.
The names of both parties, relationship, and details of the decision-making authority.
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