Parental Consent for Treatment of Minor

Parental Consent for Treatment of Minor
This form is intended to give Ball Pediatrics permission to see a minor (age 16+) without the presence of an adult/guardian. This pertains to minor sick visit/minor illnesses such as sore throat/allergies/viral illness/adhd med checks. It does not pertain to wellness checks, vaccines, or sport physicals.
I, First Name*Last Name* , am the parent or legal guardian of the child/youth named First Name*Last Name*, who was born on Date* and resides in Street AddressAddress Line 2CityStateZip .

As a parent or legal guardian, I consent for the treatment and care of the above-named child without my presence. I understand that this agreement will be in place unless given written authorization to revoke this agreement.

I understand that any payment associated with this visit should be paid prior to or on day of service in full. I understand that is my responsibility to inform the office of any updates to insurance prior to visit.

I understand that it is up to me to provide Ball Pediatrics any updates in care/medical history or concerns prior to/during the visit.
Name*

First NameLast Name
Relationship to patient *
Phone Number (to be reached in case of emergency)*
Please enter a valid phone number.
Signature*

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