Consent to Treatment of a Minor

Applicable Patient(s)*

General Consent For Treatment
I authorize GROW Pediatrics and Adolescent Medicine, PLLC and staff to provide reasonable and necessary medical examination, testing, and treatment to my child(ren) that the physician determines advisable for the child(ren)'s well-being.
This authorization has no expiration, and any changes must be made in writing.
Signature*
To Permit Specific Individuals To Accompany Child(ren)
In my absence, I may select to authorize specific individuals to accompany my child(ren) to GROW Pediatrics for the provision of medical services and to view and discuss my child(ren)'s Protected Health Information (PHI).
I authorize the following individuals to accompany my child(ren):

To Permit Only Parent/Guardian to Accompany Child(ren)
I do NOT authorize additional individuals to accompany my child.
You have indicated that you do NOT authorize anyone other that the child(ren)'s father, mother, and/or guardian to accompany child(ren) to GROW Pediatrics for the provision of medical services. Please list any explicit limitations/restrictions below:
Consent To Treat Unaccompanied Minor (16 years and older)
I request and authorize GROW Pediatrics and its staff to provide medical care to my minor child(ren) over the age of 16 years when unaccompanied for routine, preventative, and/or sick visits.
I understand I must have a valid phone number on file in my child(ren)'s chart for verification purposes.
NOTE: Per GROW Pediatrics policy, certain immunizations require the patient to stay in our waiting room 15 minutes POST administration. For their safety, please allow for this time in your child(ren)'s schedule.
I authorize my child (age 16 and older) to attend visits unaccompanied.I do NOT authorize unaccompanied visits.
Your signature below indicates that you have read, reviewed and given informed responses to this consent to treatment.
Signature of Patient/Parent/Legal Representative*
Date*

MonthDayYear
Date
Printed Name of Parent/Legal Representative*
Relationship to Patient*
Should be Empty: