Vitae Integrative Medical Center must receive permission from a child’s parent or legal guardian before providing treatments for an injury or illness that is non-life threatening. This form gives us legal permission to treat your child in case you cannot accompany him/her to the clinic for treatment. If the party accompanying your child (baby-sitter, friend, relative, etc.) does not present this information the clinic will attempt to contact you to request permission to treat your child.
Please Note: This form is valid only for a maximum of 1 year. This form allows Vitae Integrative Medical Center to bill the insurance and/or the responsible party listed on the account for all charges in connection with the care and treatment rendered. In certain circumstances, in accordance with State and Federal laws, parent/guardian permission may not be needed for adolescents being seen for concerns of “heightened sensitivity” such as STD testing, family planning, mental health, etc.