parental consent form

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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