Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Minor Treatment Consent Form
Parental/Guardian Consent for Minor Patient State and federal laws require that a parent or legal guardian provide written consent before medical treatment can be administered to a minor (under 18 years of age). By completing and signing this form, you authorize our practice to provide medical care and treatment to the minor named below. This consent covers routine examinations, diagnostic procedures, and standard treatments. In the event of an emergency, this form also serves as authorization for our providers to administer necessary emergency care to stabilize your child's condition. Please provide accurate contact information so that we may reach you promptly if needed during your child's visit.
Minor's Full Name *
Minor's Date of Birth *
____ / ____ / ________
Minor's Gender *
- Male
- Female
- Non-binary
- Prefer not to say
Parent/Guardian Full Name *
Relationship to Minor *
- Parent
- Legal Guardian
- Other
Parent/Guardian Phone Number *
Parent/Guardian Email Address *
I consent to the examination and treatment of the minor named above by the providers at this practice.
I consent to emergency medical treatment if the provider determines it is necessary to protect the health and safety of the minor.
Authorized Pickup Persons (list full names of individuals permitted to pick up the minor from appointments)
Special Instructions or Restrictions (allergies, medications, dietary restrictions, or other important notes)
Parent/Guardian Full Name *
Date *
____ / ____ / ________
Minor Treatment Consent Form template from formisoft.com. formisoft.com/intake-templates/minor-treatment-consent