PERMISSION TO INVOLVE OTHERS IN PATIENT CARE …
PRAGNESH H PATEL, M.D.* JOSE R. ARIAS, JR., M.D.
ANDREW S. BAGG, M.D.* ANDREW J. COOKE, M.D.
SONYA R. SAINI, PA-C ILANA L. STONE, ARNP-C
Board Certified Allergy and Immunology*
¡°Treating Children & Adults since 1983¡±
PERMISSION TO INVOLVE OTHERS IN PATIENT CARE
I ___________________________________am giving Allergy Asthma Specialist, PA my permission
to involve the below listed people in my complete medical care. The person/people I am listing will
share in my medical care. Allergy Asthma Specialist, PA can/will discuss (but not limited to)
testing, treatment, results of my medical care, history, including referred to Physicians/Facilities.
This permission includes financial issues involving my care (insurance, co-pays, deductibles, personal
balance, and bank charges).
Persons Name: __________________________________Relationship:_______________________
Phone Number: _________________________________ Circle one: cell home
work
Persons Name: _________________________________ Relationship: _______________________
Phone Number: ________________________________
Circle one: cell
home work
Persons Name: _________________________________ Relationship: _______________________
Phone Number: _________________________________ Circle one: cell home
work
Patient Signature: ________________________________________Date:______________________
Print Patient Name: _______________________________________ Acct: _____________________
Witness Signature: ______________________________________Date:_______________________
Print Witness Name: ______________________________________ Date: ______________________
Florida Hospital Med Plaza, 661 E. Altamonte Drive, Suite 315, Altamonte Springs, FL 32701. Ph: 407-339-3002. Fx: 407-260-5039
Dr. Phillips Medical Plaza, 7758 Wallace Rd, Suite J, Orlando, FL 32819, Ph: 407-351-4328. Fx: 407 351-1755.
Lake Bennett Medical Center, 1142 Kelton Ave, Ocoee, FL 34761 Ph: 407-219-3620 Fx: 407 219 -3621
Lost Lake Village II, 3111 Citrus Tower Blvd, Suite A, Clermont, FL 34711 Ph: 352-243-6767 Fx: 352-243-2255
Florida Hospital East Orlando Med Plaza, 7975 Lake Underhill Rd, Ste 120, Orlando, FL Ph: 407-608-7875 Fx: 407-608-7872
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