Consent to Treat a Minor Form

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Patient's Name*
Patient's Date of Birth*
Patient's Address*
Street Address Address Line 2 City State ZIP Code
Patient's Phone
Parent's Phone*
Parent's Name*
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.
Signature*
Date
Authorization to Release Healthcare Information
Name of Physician*
Names of trainers/coaches/other physicians/ other
I request and authorize the physician and/or physician's representative to release healthcare information of the patient named above to:
Signature*
Relationship to Student*
Student Signature*
Date*

Authorization to Release Healthcare Information