Consent to Treat a Minor

  • I, , parent/legal guardian of , do hereby consent to any medical care of and administration of medications determined by a physician to be necessary for the welfare of my child while said child is under the care of the above named physician and/ or their staff.

    I do hereby indemnify and hold harmless the physicians and other healthcare workers who act in reliance with this authorization.

  • Authorization to Release Healthcare Information

  • I request and authorize the physician and/or physician's representative to release healthcare information of the patient named above to: