Minor Consent Form

Minor Consent Form

All persons under the age of 18 are required to have a parent or guardian fill out this form
Minor Name*

First NameLast Name
Parent or Guardian Name*

First NameLast Name
Date of Birth of Minor*

MonthDayYear
Date
By signing below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You understand that you will be required to remain at the facility for the entirety of the minor's treatment(s). We may also request that you remain in the treatment room to supervise all interactions between the service provider and the minor.

You also agree to complete any intake and consent forms requested and have informed the service provider of any and all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).

You also understand that this service is not intened to treat, diagnose, or cure any conditions and is not a replacement for standard medical care.
By signing, I agree to the above terms and give permission for the minor to receive treatment(s) at this facility.*

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