Permission to Treat a Minor
without a Parent/Guardian Present
Patient Information
This form gives us the legal permission to treat your child in the case you are not able to attend his/her appointment. Consent includes all medical advice and treatment needed to properly care for your child. It includes, but is not limited to: office visits, in-office procedures, tests, labs, diagnostic scans, and any other medical treatment given by the treating physician.
Patient Name
Date of Birth
Today's Date
Please initial here
if you are authorizing the minor to seek and consent to treatment with no adult present.
Please initial here
if you authorize the following adult(s) to attend appointments with your child and make medical decisions in their best interest.
Any patient under the age of 16 will not be treated by our office without an adult present (19 years of age or older)
This authorization will be valid and remain effective for one year from the date listed above, or until revocation is received in writing by the parent/legal guardian.
Signature of Patient or Legal Guardian
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date