parental consent form

CLINIC
Target Clinic Policy–Providing Health Care to Minors
Generally, minors may not receive health care services without being accompanied by a parent or
guardian except in certain circumstances:
• It is an emergency.
• The service is one that state law allows a minor to provide consent for
(e.g., pregnancy-related services).
• The individual is an “emancipated” minor.
• The minor’s parent or guardian has provided written consent for another adult to accompany
the child and provide consent for treatment.
Each state defines who is a minor and what health services a minor can receive (other than
emergency services) without first obtaining consent from a parent or guardian. See below for an
overview of your state’s requirements for providing health care to minors.
Florida
Minors – Permitted Treatments
In Florida, a minor may provide consent for medical treatment or other health services only for
the following Target Clinic services: pregnancy testing. A minor may also provide consent for
treatment for his/her child.
Emancipated Minors
An emancipated minor is someone under the age of 18 who is married or has obtained a court
order of emancipation. An emancipated minor may provide consent for any medical treatment or
other health services.
Adults other than parents or guardians
An adult other than a parent or guardian may provide consent for a minor’s medical treatment if
a parent or guardian has delegated authority to that individual through a written document. If a
Guest provides you with document authorizing treatment for a minor child, scan a copy into the
patient’s eCW record.
In addition, the individuals listed below, in order of priority listed, may provide consent for
medical treatment or other health services provided by Target Clinic for a minor when, after
a reasonable attempt, the minor’s parent or guardian cannot be contacted by the treatment
provider and the minor’s parent or guardian has not provided notice that this individual is not
authorized to provide consent for the minor’s health care treatment: a person who possesses a
power of attorney to provide medical consent for the minor; a stepparent; a grandparent; an adult
sibling; or an adult aunt or uncle.

CLINIC
Target Clinic Policy–Providing Health Care to Minors
Illinois
Minors – Permitted Treatments
In Illinois, a minor may provide consent for medical treatment or other health services only for the
following Target Clinic services: pregnancy testing.
Emancipated Minors
In Illinois, an emancipated minor is someone under the age of 18 who is married, a parent,
pregnant, is in the armed forces, or has obtained a court order of emancipation. An emancipated
minor may provide consent for any medical treatment or other health services. An emancipated
minor may also provide consent for treatment for his/her child.
Adults other than parents or guardians
An adult other than a parent or guardian may provide consent for a minor’s medical treatment if
a parent or guardian has delegated authority to that individual through a written document. If a
Guest provides you with document authorizing treatment for a minor child, scan a copy into the
patient’s eCW record.
Maryland
Minors – Permitted Treatment
In Maryland, a minor may provide consent for the following Target Clinic services: pregnancy
testing.
Emancipated Minors
In Maryland, an emancipated minor is someone under the age of 18 who is married or a parent.
An emancipated minor may provide consent for any medical treatment or other health services.
An emancipated minor may also provide consent for treatment for his/her child.
Adults other than parents or guardians
An adult may provide consent for a minor’s medical treatment if a parent or guardian has
delegated authority to that individual through a written document. If a Guest provides you with a
document authorizing treatment for a minor child, scan a copy into the patient’s eCW record.
A relative other than a parent or guardian providing care for a minor may consent to health care
for the minor if there is an “informal kinship care relationship.” The relative must have proof of
this arrangement.
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CLINIC
Target Clinic Policy–Providing Health Care to Minors
Minnesota
Minors – Permitted Treatments
In Minnesota, a minor may provide consent for the following Target Clinic services: pregnancy
testing and Hepatitis B vaccinations.
Emancipated Minors
In Minnesota, an emancipated minor is someone under the age of 18 who is married, is a parent,
is in the armed forces, or lives apart from the minor’s parents and manages his/her own financial
affairs. An emancipated minor may provide consent for any medical treatment or other health
services. An emancipated minor may also provide consent for treatment for his/her child.
Adults other than parents or guardians
An adult may provide consent for a minor’s medical treatment only if a parent or guardian has
delegated authority to that individual through a written document. If a Guest provides you with
document authorizing treatment for a minor child, scan a copy into the patient’s eCW record.
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CLINIC
Target Clinic Policy–Providing Health Care to Minors
Consent To Provide Treatment For Minor Child
Child’s name __________________________________________________________________
Child’s Birth Date: Month: ______________ Day: _______________ Year: ________________
Parent’s/Guardian’s Name(s) _____________________________________________________
Contact phone number: _____________________ (work) ________________________ (home)
Alternate phone number (if not at work or home) _________________________________
Home Address
_____________________________________________________________________________
(Street)
_____________________________________________________________________________
(City, state, zip)
I (we) the parent(s) or guardian(s) named above, authorize the following adult caregiver:
Name: _______________________________________________________________________
Relationship to Child: __________________________________________________________
to consent to any necessary examination, medical diagnosis, treatment and/or care to be
rendered to the above-named minor child under the general or special supervision and on
the advice of any health care professional. I (we) agree to pay for all services provided to
my child in my absence.
Signed:
Parent or Guardian ___________________________________________________________
Date _________________________
Parent or Guardian ___________________________________________________________
Date _________________________
Office Use Only:
1. If a guest who is not the child’s parent of guardian requests treatment and needs documentation, print and provide the guest this document.
2. This document must be filled out and signed by the parent or guardian.
3. Scan this document into the patient’s electronic medical record.
4. Provide document back to the guest.
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