oviedokids.com - Consent and Authorization for Minors

CONSENT AND AUTHORIZATION FOR MINORS
By law, a health care provider must attempt to contact a birth/custodial parent or legal guardian prior to rendering treatment of a minor child ( a person under the age of 18), except in those instance where the law recognizes the minor as having the capacity to consent to a specific medical procedure/treatment. It is the policy of the Oviedo Children’s Health Center to have a signed consent form by the birth parent/custodial parent or legal guardian of a minor in order for the minor to be seen by our physicians or nurses for medical treatment. If a minor child is brought to our clinic OCHC by someone other than the birth/custodial parent or legal guardian, the minor child must be accompanied by a note (authorization). Telephone consent may be obtained from the birth parent/custodial parent/legal guardian if not accompanying the minor for care and treatment at the OCHC clinic. Telephone consent is good for single visit only and must be witnessed by two individuals.

Authorization must include the date when it was written, name of the patient, name of the person bringing the child, what the child is being seen for, the birth parent/custodial parent or legal guardians signature, copy of the birth parent/custodial parent or legal guardians photo I.D., and a telephone number where the birth parent/custodial parent or legal guardian can be reached.
I, Print name Your name And relationship to the patient Give consent for the individual identified below to bring the minor child identified below to the Oviedo Children’s Health Center for medical treatment. I hereby authorize the Oviedo Children’s Health Center, their respective Physicians and other personnel, to render medical care to my minor child in accordance with the Authorization without obtaining additional consent from me
PRINT FULL NAME OF MINOR CHILD
DATE OF BIRTH

MonthDayYear
Date
Below please add anyone that is NOT the parent that you give consent to bring Patient
WILL BE REQUIRED TO PRESENT PHOTO I.D. AT TIME OF APPOINTMENT
Purpose of Visit (sick/well/etc):
Phone number where birth parent/custodial parent/legal guardian can be reached:
This consent is for (choose one):
Single time for phone consent   Date
Specific period of time   from  Type a label to   Type a label
Indefinite period of time  from  Type a label until revoked by me
Signature of parent/custodial parent/legal guardian:

Clear
Date:

MonthDayYear
Date
ATTACH COPY OF PHOTO I.D.
Print Witness Name:
Date:

MonthDayYear
Date
Signature of Witness:

Clear
Date:

MonthDayYear
Date
Should be Empty:

CONSENT AND AUTHORIZATION FOR MINORS

WILL BE REQUIRED TO PRESENT PHOTO I.D. AT TIME OF APPOINTMENT

ATTACH COPY OF PHOTO I.D.