Consent to Treat an Unaccompanied Minor

Please correct the errors described below.
(Name of Legal Guardian)
(Name of Child Age 16-18 years old)

to attend ill OR well visit appointments alone, without the presence of a legal guardian or authorized adult. I authorize treatment for my child in accordance with the policies of Bloomington Pediatrics, LTD. This includes providing a history of present illness, disclosure of protected health information, and responsibility for relaying any diagnosis, treatment plan, forms or prescription(s) to the parent or legal guardian mentioned above. I agree to be available by phone and to be financially responsible for all copays, deductibles and/or coinsurance resulting from the visit.

(Today’s Date)
(Date Authorization is no longer valid)

Child’s Health Information

Currently prescribed or over-the-counter medications and dosages:

Add new medications and dosages:

Emergency Contact Information for Parents/Legal Guardians

Health Insurance Information

If Insurance information has changed, please complete the following and plan to send the card with your child for scanning into their record.

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.

Your information will be encrypted.