The nature of the medical treatment to be given under this authorization is for preventive care, urgent care, or acute care
problems beginning on the date this authorization is signed. I understand that even if I sign this authorization, South Austin
Medical Clinic will not be able to perform any invasive procedures unless a parent, legal guardian, or managing conservator
accompanies the minor to their appointment. If such services need to be performed, another appointment will need to be
scheduled in which the parent, legal guardian, or managing conservator must be in attendance.
I specifically authorize the individual(s) listed above to also give consent for my minor child to receive recommended or scheduled immunizations. *I understand that I am required to give this individual(s) sufficient and accurate medical history and other information about my minor child and his/her family for whom the consent is given to determine the risks and benefits inherent with the immunization and to determine whether immunization is advisable. Please Initial: Yes No
I understand that there are certain circumstances where a minor can legally consent to his/her own treatment without parental consent including, but not limited to treatment for: the diagnosis and treatment of an infectious, contagious, or communicable diseases that are reportable to the Texas Department of State Health Services (DSHS), treatment related to pregnancy, treatment for drug or chemical use, counseling for suicide prevention , chemical addiction or dependency, or sexual, physical, or emotional abuse.