pearlpediatricclinic.com - Consent 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 instances where the law recognizes the minor as having the capacity to consent to a specific medical procedure/treatment. It is the policy of the Pearl Pediatric Clinic to have a signed consent form by the birth parent/custodial parent or legal guardian of a minor for the minor to be seen by our physicians or nurses for medical treatment. If a minor child is brought to our clinic Pearl Pediatric Clinic 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 Pearl Pediatric Clinic. Telephone consent is good for a 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, Your Name and Relationship to the Patient Give consent to the individual identified below to bring the minor child identified below to Pearl Pediatric Clinic for medical treatment. I hereby authorize the Pearl Pediatric Clinic, 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.

FULL NAME OF MINOR CHILD

DATE OF BIRTH

Date

Below please add anyone that is NOT the parent that you give consent to bring Patient

NAME OF PERSON BRINGING MINOR CHILD FOR APPOINTMENT

RELATIONSHIP TO MINOR

NAME OF PERSON BRINGING MINOR CHILD FOR APPOINTMENT

RELATIONSHIP TO MINOR

NAME OF PERSON BRINGING MINOR CHILD FOR APPOINTMENT

RELATIONSHIP TO MINOR

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 visit on Date: Date
Specific period , fromDate to Date
Indefinite period from Date until revoked by me

Signature of parent/custodial parent/legal guardian:

Date

Upload Copy of Photo I.D.

Witness Name:

Date:

Date

Signature of Witness:

Date:

Date

CONSENT AND AUTHORIZATION FOR MINORS