Enspire Consent to Treat Minor Patient-Without Parent/Legal Guardian Present

Consent to Treat Minor Patient-Without Parent/Legal Guardian Present
By law, any child under the age of 18 years old cannot be seen by a provider without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf.
Minor's Name:*

First NameLast Name
DOB:*

MonthDayYear
Date
LIMITATIONS:
Identify any specific limitations on the kinds of medical services for which this authorization is given. (If none, state “none”) blanks blank
AUTHORIZATION:
I (parent/legal guardian name) blanks request and authorize Medical Wellness Center of Georgia and its personnel to deliver routine medical care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of the minor child. I am also aware that the adult presenting the child is responsible for payment of the patient portion at the time of service.)
I have read, understand, and give my consent as stipulated above. My signature means that I have read this form and/or have had it read to me and explained in the language that I can understand.
Parent or Legal Guardian Relationship*
Parent or Legal Guardian (Please Print) Name

First NameLast Name
Parent or Legal Guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty: