Consent to treat Minor Patient

Consent to treat Minor Patient

Without Parent/Legal Guardian Present
Consent to treat Minor Patient-Without Parent/Legal Guardian Present

By law, any child under the age of 18 years old cannot be seen by a doctor without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf.
Minor's Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
For those occasions when you may not be with your child, please list those individuals who may give us consent to see your child:
Name
Relationship to Patient
Name
Relationship to Patient
Identify any specific limitations on the kinds of medical services for which this authorization is given. (If none, state “none”)
Type a question

Check here if you wish to give consent for the minor to receive medical care without an accompanying adult. This consent may only apply to minors age 16 and older.
This consent shall be in effect for:

A Specific Date Onlyindefinitely, until revoked by written communication
Specific Date if selected above

MonthDayYear
Date
AUTHORIZATION:
Parent/Legal Guardian Name

First NameLast Name
I request and authorize Glacier Medical Associates and its personnel to deliver routine medical care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of the minor child. I am also aware that the adult present the child is responsible for payment of the patient portion at the time of service.

I have the legal right to preauthorize Glacier Medical Associates and its personnel to deliver routine medical treatment and services to my child. Routine medical care and interventions may include, but are not limited to: medical evaluation, physical exam, routine immunizations, injections, x-rays, lab work (examples: throat or nasal swabs, blood draws, wart treatment with liquid nitrogen, minor burns, minor suturing of lacerations) I have read, understand, and give my consent as stipulated above. My signature means that I have read this form and/or had it read to me and explained in the language that I can understand.
Parent/Legal Guardian Name

First NameLast Name
Relationship to Patient
Parent or Legal Guardian Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Consent to treat Minor Patient

AUTHORIZATION: