Pediatric Health Associates of Naperville
Naperville  |  North Aurora  |  Plainfield  |  West Chicago  |  Bolingbrook

Immunization and Treatment Policy

Patient Account Number:

Pediatric Health Associates requires a parent/legal guardian to accompany their child to each and every office visit.

In the event that this is not possible, then a written release must be provided to PHA including the following:

  1. Date the release is written
  2. Child’s name
  3. Child’s date of birth
  4. Parent/legal guardian signature
  5. Phone number where parent/legal guardian can be reached in case of an emergency
  6. Person authorized to accompany your child and make medical decisions in the event that a parent/legal guardian cannot be contacted.

Please note this person’s relationship to the parent and child. This is only effective for one date of service.

Please note that immunizations/allergy shots will only be given in the presence of the parent/legal guardian. Any other requests outside these guidelines must be approved in writing by our nursing manager.