Parental Advance Consent to Treat Minors

Manhattan Primary Care

Bradley K. Harrison MD, FAAFP Kerri Maxcy PA-C Kyle E. Platz DO, FAAFP
PARENTAL ADVANCE CONSENT TO TREAT MINORS
In the event that you are unable to accompany your child to their doctor’s appointment, we are required to obtain parental consent prior to treating a child. When parents are not immediately available, this can take time, and delay treatment.

This is to certify that the person/s listed below has my permission to authorize necessarymedical care for my child. This authorization will be in effect until revoked in writing by me oruntil my child(ren) turn(s) 18 year of age. I accept financial responsibility for necessary treatment and services.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Other Child(ren) covered under this authorization (please list name and birth date)
Person(s) (Non-parent) authorized to seek medical care for the above listed child(ren)
Parent/Legal Guardian Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Manhattan Primary Care