FAMILY TREE CLINIC PARENT/GUARDIAN CONSENT FORM

PARENT/GUARDIAN CONSENT FORM
Adolescents under age 18 must have a signed parent/guardian consent form on file to receive some general medical services. 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. * Note: A signed parent consent form lasts until the child turns 18, unless withdrawn.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.*
Patient Name (preferred):*
Birth date:*

MonthDayYear
Date
Patient Legal Name (name listed on insurance card):*
This name will be used for prescriptions, lab orders and mail. Bills will be sent to the insurance company or mailing address by this name.
By my signature below, I confirm:
- I am the legal parent or guardian of the above named minor, and I have the legal authority to consent to medical care for the above named minor.
- I am allowing the above named minor to receive medical care at Family Tree Clinic.
- I give permission to bill my health insurance carrier or Medical Assistance for general medical services received. This would also apply if you do not currently have insurance but get it later.
- I have received the notice of privacy practices stating I may have access to my child’s general medical record but not to any confidential services provided, as stated in the Minnesota Statute 144.341-347.
- I understand I will be notified in case of emergency or need for follow up medical care.
Please include information for any and all legal parents / guardians:

If there are more than two legal parents / guardians, please have them submit an additional form.
Print parent/guardian name*
Date of birth*

MonthDayYear
Date
Preferred Name & Pronouns
Phone number*
Relationship to patient*
Today's date*

MonthDayYear
Date
Parent/guardian signature*

Clear
Print parent/guardian name
Date of birth

MonthDayYear
Date
Preferred Name & Pronouns
Phone number
Relationship to patient
Today's date

MonthDayYear
Date
Parent/guardian signature

Clear
If you have any concerns regarding this consent form, please contact the Clinic Director at (612)473-0800.
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