Consent To Treat a Minor

Consent To Treat a Minor
The following form is designed for those situations where minors are unaccompanied by either parents or legal guardians. This "Parental Consent to Treat A Minor Form" gives authority to a designated adult to arrange for

Medical care cannot be provided to a minor without the approval by the parents or legal guardians, unless there is written consent authorizing an agent to give approval. In addition, a copy of the Parent/Legal Guardian photo ID must be provided with consent.

Patient Name*
Date of Birth*

MonthDayYear
Date
Visit Date

MonthDayYear
Date
I   Parent/Guardian First Name*  Parent/Guardian Last Name*, am the Parent/Legal Guardian of the child listed below and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.

I authorize   First Name of person I am Authorizing*   Last Name of person I am Authorizing* to provide the following:

Provide transportation to/from visit   Power to consent to necessary medical or mental health at the time of the patient's visit*