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Minor Treatment Consent Form
Consent

Minor Treatment Consent Form

2 pages•7 fields•HIPAA-ready
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Minor Treatment Consent Form
Child's Name & Date of Birth
Parent/Guardian Name
Relationship to Child
Select...
Minor Treatment Consent
I agree to the terms above
Sign here
Designated Responsible Adults
Submit
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The Minor Treatment Consent Form provides the legal authorization required to treat patients under the age of 18. It captures the parent or legal guardian's consent for medical examination and treatment, including emergency medical care authorization in the event the guardian cannot be reached.

The form documents the relationship between the consenting adult and the minor patient, verifying legal authority to provide consent. It covers routine medical care, emergency treatment authorization, and specific procedure consent when applicable. Designated responsible adults are listed with contact information for situations where the guardian is not present -- such as grandparents, babysitters, or family friends who may bring the child to appointments.

Additional sections cover immunization consent, prescription medication authorization, and any treatment restrictions the guardian wishes to specify (e.g., religious objections to blood products, allergy concerns). This form is essential for pediatric practices, school health clinics, summer camps, daycare medical authorizations, and any healthcare setting that treats minors. It provides legal protection for providers while ensuring that guardians maintain appropriate oversight of their child's care.

What's included

  • Parent/guardian identification and verification
  • Treatment consent agreement with e-signature
  • Designated responsible adults for pickup
  • Immunization and prescription authorization
  • Treatment restrictions and special instructions
  • Emergency medical authorization

Who uses this template

  • Pediatric practices and children's hospitals
  • School health clinics and camp medical programs
  • Daycare and childcare medical authorization
  • Any practice treating patients under 18

All form fields

5 fields across 2 pages. Customize any field after signing up.

Child's Name & Date of BirthText
Parent/Guardian NameText
Relationship to ChildDropdown
Minor Treatment ConsentConsent Agreement
Designated Responsible AdultsLong Text

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$79.99/mo · 14-day free trial · HIPAA compliant

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