Johns Creek Vickery Village | Authorized Patient Information List

I authorize all Dominion Orthopaedic Clinic LLC physicians and or whomever he/she may designate as his/her professional representative/assistant to discuss any aspect of my orthopaedic care, to include: appointments, tests, test results, surgical procedures, prescriptions, and any other pertinent information pertaining to my care with the following designated people.
Persons Name Relationship
This document will be part of your permanent record. In the event that any of the selected representatives that you have designated change, it will be necessary to update our records with written notification. You will need to state who you would like to have removed or added to the Authorized Notification List.
Patient/or other authorized person signature*
Relationship
Date*
Witness Signature*
Date*