Consent to Medical Services for a Minor

Consent to Medical Services for a Minor
I am the parent or guardian of First Name* Last Name*, date of birth: Date* , a minor. I am legally authorized to provide informed consent for him/her. If I am unable to accompany my son/daughter to a medical appointment, I want Heartland Health Center, Inc., (“the Clinic”) to:
Call me for any and all needed consents.The Clinic can provide the medical services I initial below without obtaining further consent from me. I understand that if I initial a medical service, no further consent from me will be needed for that medical service. Please Indicate your consent by initialing as appropriate
My cell phone number is
Please enter a valid phone number.Format: (000) 000-0000.
Routine Office Visits, including    insert office visits

Laboratory Tests, including blood tests or cultures

Office Procedures, including   insert office procedures

Prescriptions/Injections, including   Insert prescriptions, injections, etc.   etc.

Other   Insert other
I understand and agree that (1) I am financially responsible for all medical services provided by the Clinic to the minor; (2) any consent I provide in this document will be effective until the minor is age 19, is married, is emancipated, or I provide written notice to the Clinic, to its Clinic Manager, that I am revoking my consent; and (3) a minor may consent to some medical care under state law, such as treatment for STDs, and can control access to and the release of his/her medical records for that care apart from any consent in this document.
Parent/Guardian Signature*

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Date*

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Date
Printed Name*

First NameLast Name
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