Teen Consent

Adult Consent for 18 Years and Older
Name

First NameLast Name
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Now that you are over the age of 18, we need your permission to share medical information with anyone other than you. Please sign the waiver below to let us know if we have your permission to share your information, and with whom.

I give my permission to share my medical information with:
Mom (Name)

First NameLast Name
Dad (Name)

First NameLast Name
Other (Name)

First NameLast Name
You may share:
Signature
Form Disclosure

By submitting this form, you agree that [Practice Name] may use the information you provide to respond to your request and, where applicable, to contact you about your child's care. We do not sell your information. View our full Privacy Policy at https://www.rtcpeds.com/privacy-policy.
Should be Empty:

Adult Consent for 18 Years and Older