graphic: kids

Is Your Child Sick?TM

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

Medical Decision Authorization







By signing this medical decision authorization form, I am stating that I am the parent and/or guardian for the above named patients and am legally responsible for making any and all decisions regarding their medical care. I also authorize the following people to bring my children in to the office of Reis Pediatrics for medical care and to make medical decisions in my absence (please note any exceptions):














I also authorize the people I have listed to pick up any medical records/forms on my behalf.

ID CARD WILL BE REQUIRED.