Parental Consent to Treat

Name of Minor

Date of Birth

Parental Consent for Medical Services to Minors

Name of Minor

Date of Birth

I am listing the names of the people that I have given permission to bring my child/children to the medical office in my absence.

Name

Relationship to Minor:

Name

Relationship to Minor

This consent pertains only to the minors listed above. Each person who will bring the child/children to the medical ooffice is required to bring picture ID for identification on verification.

I understand that I am accepting financial responsibility for all medical services rendered for the patients and that payemnt is due at the time of service. I have the right to revoke this consent in writing.

Signature of Parent/Legal Guardian

Relationship to Patient

Print Name

Today's Date

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