Consent to Treat Minors

Forward Care Family Practice, PLLC

Fax: 833-974-2347 (Main Office)
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Consent from Parents or Guardians for Authorized Persons:

As the parent or guardian of for the below listed person(s) to bring my child in for treatment and/or care.

PLEASE SELECT ONE OF THE FOLLOWING CHOICES:

I am granting full permissions, meaning the below-listed person(s) will be allowed to agree to treatments/vaccines, and know all health history pertaining to my child.

I am granting permissions, meaning the below-listed person(s) is only allowed to bring my child in, and will have access to all health history, but not allowed to agree to treatments without my direct consent.

I am granting limited permissions, meaning the below-listed person(s) is allowed to bring my child into the office, but is not allowed access to any medical information or treatment of my child. I will be informed of the visit results, and I will be notified prior to any treatment for my child.
Parent or guardian of.*
Granting full permissions, Initials.*
Please list person(s) here*
Relationship*
I am granting permission to Forward Care Family Practice to leave phone messages regarding my child's medical health to the number(s) provided on the registration form.
Parent/Guardian Signature*

Clear
Date*

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Witness Signature*

Clear
Date*

MonthDayYear
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Should be Empty: