AUTHORIZATION TO TREAT A MINOR CHILD IN ABSENCE OF A PARENT

Authorization to Treat a Minor Child in Absence of a Parent or Legal Guardian
Please check on of the following:

The minor child under my legal care is 15-17 years of age, and I give my consent for him/her to attend an unaccompanied appointment. In addition, I give my consent for medical care as described below.The minor child under my legal care is under 15 years of age, and I give my consent to him/her to attend an appointment accompanied by an adult representative greater than 18 years of age as designated below. In addition, I give my consent for medical care as described below. Please note: stepparents must be given authorization.
Parent or Legal Guardian's Name:*

First NameLast Name
Patient's Name:*

First NameLast Name
Patient's Birthday:*

MonthDayYear
Date
Parent or Legal Guardian's Number:*
Please enter a valid phone number.
Authorization:

I, the parent or legal guardian of the above-named child, hereby authorize the following individuals to accompany my child to office visits with ORA Orthopedics and consent to the examination and/or treatment of my child during the office visits.

Please fill out up to three names and define the individuals relationship to the child.
1. Name and Relationship to Child:

First and Last NameRelationship
2. Name and Relationship to Child:

First and Last NameRelationship
3. Name and Relationship to Child:

First and Last NameRelationship
Medical Care:

The undersigned hereby authorizes ORA Orthopedics to provide ongoing medical treatment, by physician or physician assistant (including support staff) employed by ORA Orthopedics for my minor child when such treatment is deemed necessary by the provider in conjunction with the injury or condition being treated. Such consent may include, but is not limited to medical treatments, tests, x-ray (imaging) examinations, injections, and/or prescription medications.

NO test results will be given without a parent or legal guardian present at appointment.
This authorization:

is only effective on the date indicated belowis effective from the start and end dates indicated belowis effective until revoked by me in writing
If you selected "only effective on the date indicated below" or "effective from the start and end dates indicated below," please enter the date(s) in the appropriate field(s).
Only Effective on this Date:

MonthDayYear
Date
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
First and Last Name of Parent or Legal Guardian:

First NameLast Name
Signature of Parent/Legal Guardian: *

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Date
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Authorization to Treat a Minor Child in Absence of a Parent or Legal Guardian