Parent and Minor Confidential Agreement

Please correct the errors described below.

The state of Maryland grants minors the right to confidential medical care regarding contraception, pregnancy, and sexually transmitted disease testing and treatment. We encourage full communication between a minor and her legal guardian.

Whether or not this supplemental form is signed, we will uphold the state and federal laws regarding confidential health care information.


to enter a confidential patient-physician relationship. I understand that my daughter can make independent health care decisions, but that my input and involvement will be encouraged.

My daughter has permission to schedule appointments and receive confidential reports from this office, I further understand that various laboratory tests may be necessary in medical protocols and accept responsibility for physician charges and laboratory fees.


I will make an effort to communicate with my parent(s) about issues concerning my health. I accept the personal responsibility of being honest and will follow the health care recommendations my physician and I establish.

Permission to Treat Minor Patient without Parent/Legal Guardian Present

Capital Women’s Care must receive permission, from a child’s parent or legal guardian, prior to providing treatment(s)for preventative care, injury or illness that is non-life threatening. This form provides the legal permission to (depending on the minor's age) either treat without any adult present (Section A), or with a Designated adult present (Section B)

Section A: (ONLY for child at least 16, but not 18 years old)

Authorization to treat your minor child in case you or your designated representative are unable to accompany your child to one of his/her visits:

Section B: (for child under 18 years old)

Delegation of authority for medical treatment of a minor child to the designated representative indicated

Add Authorized Person/Adult

I also agree to be financially responsible for payment of all charges in connection with the care and treatment rendered.

NOTE: A parent / legal guardian MUST be present for a minor patient’s first visit with Capital Women’s Care.

Formatted text

Please Note: Insurance card(s) and co-pay amounts (if applicable) must be presented at each visit.

NOTE: Annotated Code of (State Law) allows for the following exceptions, where a minor has the same capacity as an adult to consent to medical treatment:

  1. Treatment for and/or advice about drug abuse, alcoholism, venereal disease, or pregnancy other than sterilization.
  2. Physical exam for and treatment of injuries and/or collection of evidence from an alleged rape or sexual offense.
  3. Consultation, diagnosis and treatment of a mental or emotional disorder.

Your information will be encrypted.