Did you know you could do all these things online through EPIC MyChart?

  • schedule an appointment
  • request prescription refills
  • request referrals
  • contact your doctor

Authorized Representative

before your visitother forms

Please download, fill out, and return this form if you would like to give Westwood-Mansfield Pediatrics permission to discuss your healthy care with an authorized representative. This is necessary if you would like a grandparent or nanny to be able to bring children to their visits.

In addition, if you are 18 years old (or older) and would like us to be able to speak with a parent about aspects of your health care, you will need to complete this form and name your parent as an Authorized Representative.

 

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