• 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 * Note: A signed parent consent form lasts until the child turns 18, unless withdrawn.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.*

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  • My child has my permission to receive general medical services at Family Tree Clinic.

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  • Clear
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  • IMPORTANT INSURANCE INFORMATION: PLEASE FILL IN ANY/ALL OPTIONS BELOW THAT APPLY TO YOUR CHILD. 

  • If you have any concerns regarding this consent form, please contact the Clinic Manager at (651)645-0478.

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