Consent to Treat Minors

If someone other than the parent brings your child in for an appointment, we must have the parent’s written authorization in order to provide medical care.

the parent or legal guardian of

Date of Birth

authorize my child to be treated.

Also, I authorize

to bring my child in for medical treatment and to receive my child’s Patient Health Information.

Their relationship to patient:

Treatment may include (please check):

General and ongoing medical care

Minor surgery which may be accompanied by the administration of local injectable lidocaine

This authorization is effective (please check)

Today Only

From

To:

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.

Parent or Legal Guardian Signature:

Date:

Your information will be encrypted.