"*" indicates required fields Parent Name* First Last Child's Name* First Last Child's Date Of Birth* Month Day Year I hereby give permission for the above named child to be treated by the physicians and staff members at Arizona Allergy Associates.* In my absence, this minor may be evaluated in the clinical setting (office visit) and receive allergy injections, biologic injections, and complete testing as deemed medically appropriate. In my absence, I give permission for this child to be promptly treated for any reaction or emergency by any of the clinicians available. Additionally, protected patient health information may be shared with the proxy to facilitate informed decision-making. Decline Check which one applies.* I understand that the Responsible Party must be 18 years or older. I authorize my underage child (16 or 17) to bring themselves in for treatment and they have the ability to understand the risks and benefits of treatment. I also understand that my underage child must be accompanied by a parent/guardian for any office visits. This authorization is valid for 1 year from the date of signing and may be revoked at any time providing written notice of revocation.* I understand I cannot revoke this authorization retroactively for treatment already provided.Name of Proxy First Last Relationship to Minor* Signature* Type name for signature.Today's Date* Month Day Year Consent* By clicking submit I agree that I have read and will abide by all of Arizona Allergy Associates policies and that all information provided is accurate. Additionally, I acknowledge that this will serve as my electronic signature. Δ