Consent To Treat Unaccompanied Minor (Under The Age Of 18) printable pdf download

Chippewa County – Montevideo Hospital

CONSENT TO TREAT UNACCOMPANIED MINOR (Under the age of 18)

CCMH must receive permission from a child’s parent or legal guardian before providing treatment for any

injury or illness that is non-life threatening. This form gives our office the legal permission and consent to

treat your child in case you cannot accompany him/her. If your child or the party accompanying your

child (baby-sitter, friend, relative, etc.) does not present this form, our office will attempt to contact you to

request verbal authorization to treat your child.

The verbal authorization will be documented in your child’s medical records.

Please Note:

- A parent/legal guardian MUST be present for their child’s first visit to CCMH.

- A new “Permission to Treat a Minor” form is required for each visit that a minor will be seen without

his/her parent/legal guardian.

PATIENT NAME: _____________________________________________________________________________

PATIENT DATE OF BIRTH: _____________________TODAY’S DATE: _________________________________

I, __________________________________, grant _______________________________ (an adult

Parent/Legal Guardian Accompanying Party into whose care, the minor has been entrusted) to arrange

for and authorize routine and emergency treatment at CCMH for the following date: _____________ (this

date indicates when this form is valid.) This authorization grants consent to any x-ray, examination,

treatment, medical or surgical diagnosis.

Parent/Legal Guardian Signature: ______________________________________________________

Printed Name: ____________________________________________ Date: _____________________

Relationship to patient: ____________________________________

Please be sure to send the insurance card and co-pay (if applicable) to the appointment.

In case of Emergency, I can be reached at:

Home: __________________ Work: _____________________ Cell: _______________

Please send current insurance information with your child or the party accompanying them.

Verbal Permission is given by parent or legal guardian for child’s visit on ________________________.

CCMH Staff Signature: ______________________________CCMH Staff 2nd Signature: _____________________________

Staff Name (Please Print) ____________________________ Staff Name (Please Print) _______________________________

824 North 11

Street * Montevideo, MN 56265-1683 * (320) 269-8877 Phone * (320) 269-8166 Fax

Consent To Treat Unaccompanied Minor (Under The Age Of 18)