Consent Form for Minor to Receive Care

Consent Form for Minor to Receive Care
Consent Form for Minor to Receive Care
I First Name* Last Name* of City*, State* do hereby state that I am the parent/legal guardian of: Child's full name* DOB* who resides with me at Street Address* City* State* Zip* .

By signing below, I authorize Family Medicine Associates of Midland to provide medical care for the above named minor.

*In no event shall this delegation of parental rights be effective for more than one year from the date listed below.
Signature of parent/guardian*
Date*

MonthDayYear
I understand that this form will be placed in my child's medical record and will be used for the sole purpose of treating my child at the above named clinic.

Send a list of any medications your child is currently taking with the individual that will be bringing them.
Should be Empty: