Parental Consent Form

Parental Consent Form

By law, any child under the age of 18 cannot be seen by a healthcare provider without consent from a parent or legal guardian. If a minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian for the adult to act on your behalf.
Patient Name*

First NameMiddle NameLast Name
Sex*
Date of Birth*

MonthDayYear
How long is this consent valid?*

The patient may receive medical care without an accompanying adult indefinitely, until consent is revoked in writing.The patient may NOT receive medical care without an accompanying adult.
For those occasions when a parent/guardian are unable to accompany the minor to his/her appointment, please list the names of individuals who may give us consent to see the minor.

First NameLast Name
Relationship to Patient
Contact Number:

Area CodePhone Number
First NameLast Name
Relationship to Patient
Contact Number:

Area CodePhone Number
Please list any medications the patient currently takes.
Does the patient have drug allergies?

YesNo
If yes, please list the names of the medications the patient is allergic to here.
Limitations: Please specify any limitations on the kinds of medical services for which this authorization is given. (If none, state none.)
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Authorization*
Name of Parent or Legal Guardian Completing this Form*

First NameLast Name
Relationship to Patient *
Signature of Guardian/Parent*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty: