Parent/Guardian Consent Form

Please correct the errors described below.

*Note: A signed parent consent form lasts until the child turns 18, unless withdrawn. If the consent form is not returned, anyone under 18 will not be able to receive general medical services, however confidential reproductive health services are available by state law. *

Adolescents under age 18 must have a signed parent/guardian consent form on file to receive some general medical services (including vaccines unless otherwise stated). * According to state law, parental consent is NOT required for pregnancy and contraceptive services, chemical abuse assessment and counseling, or diagnosis/testing and treatment of sexually transmitted infections. If you have any concerns regarding this consent, please contact the office.

My teen has permission to receive medical service at Pediatric Associates.

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