Limited COVID-19 vaccines are available for ages 5-11 at select locations by appointment,
including Woburn, MA; Parkland, FL; Cary, NC; Los Angeles, CA; Naperville, IL; Mount Prospect, IL; Greenbelt, MD; Manhasset, NY; Livingston, NJ; Fairfax, VA; & Round Rock, TX & The Colony, TX.
For your convenience, we have provided the following patient forms:
• Patient HIPAA Authorization
• Temporary Guardianship Consent
Please fill out the forms below as needed and fax or hand deliver to your local office.
• Please fax or hand deliver to the office you were seen in
Please fill out the form below to authorize temporary consent for your child to be seen at PM Pediatrics with an adult other than yourself. Please submit this form to your nearest office along with a copy of your photo ID.
IMPORTANT: This form is valid for one calendar year and must be renewed each year in order to be considered valid.