Treatment of a Minor Consent

Treatment of a Minor Consent

Parental Delegation
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. I give my consent to Heartland Health Center, Inc. (“the Clinic”) to provide routine or emergency medical, mental health or dental treatment to my child.
My child is currently taking the following medications:
My child has the following allergies:
Further, I authorize and give full authority and power to   First Name*   Last Name*   to consent to the treatment of my child in my absence.

His/her address is   Street Address*      City*   State*   Zip*

and his/her telephone number is   Area Code*   Phone Number*   .
I understand that this consent is given in advance of any specific diagnosis and such a diagnosis may later require my specific informed consent before treatment can be provided.

I understand and agree that (1) I am financially responsible for all medical or dental services provided by the Clinic to the minor; (2) any consent I provide in this document will be effective for six (6) months from the date of my signature or until the minor is age 19, is married, is emancipated, or I provide written notice to the Clinic, to its Clinic Manager, at the address above, 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*

MonthDayYear
Date
Printed Name*

First NameLast Name
Relationship to Minor*
Should be Empty: