CONSENT FOR MEDICAL TREATMENT OF MINOR

Name of Minor:

Birth Date:

Age:

COMPLETE SECTION A OR B

SECTION A: consent by parent/managing conservator/guardian or other adult

Name of Parent(s) if known:

Name of Managing Conservator/Guardian (if applicable):

I am the (select one):

Parent Managing conservator Guardian of the above named minor

Complete this section ONLY if the parent/managing conservator/guardian CANNOT BE CONTACTED.

The person having the right to consent to medical treatment for the above minor (parent/managing conservator/guardian) cannot be contacted and has not given notice to the contrary. As per Texas Family Code Chapter 32.001, I may consent for medical treatment of the above named minor.

I am the (select one):

grand parent adult brother/sister adult aunt/uncle educational institution with authorization to consent from a person having the right to consent adult with care/control/possession with written authorization to consent from the person having the right to consent adult responsible for minor under juvenile court order Texas Youth Commission staff

I give permission for Bay Area Obstetrics & Gynecology, P.A. to provide confidential medical treatment, including contraceptive services, to the minor named above. This consent begins on the date below and remains in effect unless revoked in writing.

I declare under penalty of perjury that the above information is true and correct.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name/Signature of Person Giving Consent:

Date:

SECTION B: consent by minor client

I am an emancipated minor.

I am age 16 or older, living separate and apart from my parents/managing conservator/guardian, and manage my own financial affairs.

I declare under penalty of perjury that the above information is true and correct.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name/Signature of Minor:

Date:

Your information will be encrypted.