Confidential  Agreement

I, _____________________________________ (parent or guardian), allow

______________________________________ (patient), to enter a confidential patient-physician relationship. I understand that she can make independent health care decisions, but that my input and involvement will be encouraged.

______________________________________ (patient) has permission to schedule appointments and receive confidential reports from this office. I further understand that various laboratory tests may be necessary in medical protocols and accept responsibility for physician charges and laboratory fees.

_____________________________________ _____________________

Parent or Guardian                                                      Date

_____________________________________ _____________________

Physician                                                                      Date

I, ______________________________________ (patient), am entering a confidential physician-patient relationship with

_____________________________________ (physician). I will make an effort to communicate with my parent(s) or guardian(s) about issues concerning my health. I accept the personal responsibility of being honest and will follow the health care recommendations my physician and I establish.

_____________________________________ _____________________

Patient                                                                         Date

_____________________________________ _____________________

Physician                                                                     Date