Consent for Minor and/or Adult with Guardian

CONSENT TO TREAT: I grant permission for the Center to perform medical, behavioral health, and/or dental care on my child with or without my presence. This may include routine diagnostic and medical treatment that the attending providers or others of the health center medical staff consider necessary. Services could include treatment for illness or injury, including over the counter medications or necessary prescriptions, well child exams, appropriate immunizations, behavioral health evaluations, dental cleanings, x-rays, fluoride treatments, sealants, and limited restorative dental treatments. Attempts will be made to notify the parent/guardian of the minor’s appointment and to see if they wish to attend the visit. If no contact is made and all consents are in place, the Center will continue the appointment as needed and attempt contact the parent with follow-up information following the appointment including sending home a copy of the care summary.

AUTHORIZATION FOR EXCHANGE OF HEALTH INFORMATION: I hereby authorize Community Health Center of the New River Valley’s School Program to exchange health records with the appropriate school district for the purpose of providing care and treatment.

INFORMED CONSENT FOR GENERAL OR REMOTE SUPERVISION: I understand that the records for services provided by the dental hygienist will be reviewed by a Virginia licensed dentist providing the hygienist general supervision. I understand that treatment I receive from the dental hygienist is limited in scope and that it does not take the place of a regular dental examination or treatment by a licensed dentist. I understand that the dental hygienist may refer to a dentist or other specialist for further treatment when a dental condition requires more treatment that the dental hygienist can provide.

By signing below, I agree that I have provided accurate answers. I have reviewed the acknowledgements and authorizations and agree to adhere to the requirements as written. I have reviewed the Notice of Privacy Practices. My signature demonstrates consent and acknowledgement of all patient responsibilities and rights as outlined in this patient registration packet. It is my responsibility as a patient to contact the previous provider’s office to transfer medical records. I can ask for a copy of my medical records at any time.