RBH CONSENT FOR TREATMENT OF A MINOR
Today's Date:
-
Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Patient DOB:
-
Month
-
Day
Year
Date
Who does Patient Live with the Majority of the Time?
Both Biological Parents
Adoptive Parents
Biological Mother
Biological Father
Grandparent
Other Legal Guardian
Biological Mother's Name:
First Name
Last Name
Biological Mother's Phone #:
-
Area Code
Phone Number
Biological Mother's Email:
example@example.com
Biological Father's Name:
First Name
Last Name
Biological Father's Phone #:
-
Area Code
Phone Number
Biological Father's Email:
example@example.com
Adoptive Parent:
First Name
Last Name
Adoptive Parent Phone:
-
Area Code
Phone Number
Adoptive Parent Email:
example@example.com
Biological Parents Marital Status:
Are Either of the Biological Parents Deceased:
No, Both Biological Parents are Living
Biological Mother Deceased
Biological Father Deceased
Unknown
If parents are divorced or separated, please list which parent is the court-appointed Custodial Parent or Primary Managing Conservator who has the legal right to consent for treatment of a minor:
Both Parents/Joint Managing Conservatorship
Biological Mother
Biological Father
Adoptive Parent
Legal Guardian
Have you provided a copy of the Divorce Decree to the RBH front office?
Yes
No
N/A - not divorced
RBH requires a copy of the Divorce Decree to be submitted to the front office at the time of intake.
Are there any step-parents, adoptive parents, or grandparents who have been granted legal authority to Consent for Treatment of a Minor?:
Yes
No
N/A
Does the Patient have a Court Appointed Power of Healthcare Attorney or Legal Guardian??
Yes
No
If Yes, List Healthcare Power of Attorney Legal Guardian Name
First Name
Last Name
Legal Guardian Phone Number
-
Area Code
Phone Number
Legal Guardian Email:
example@example.com
Who Does Patient Live with the Majority of the time?
Both Biological Parents
Biological Mom
Biological Dad
Other Legal Guardian
Adoptive Parents
Signature of Consenting Parent / Legal Guardian:
My signature confirms that the entries herein are an accurate and true representation of the legal rights for providing Consent for Treatment of a Minor.
Clear
Printed Name of Consenting Parent/Legal Guardian:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: