Minor Patient Treatment Consent Form printable pdf download

Minor Patient Treatment Consent Form

Ear, Nose, and Throat Associates

Watauga Hearing

Please complete this Form if Patient is a Minor

Patients under the age of 18 must be accompanied by the parent or guardian at each visit. The parent who brings the minor

patient to the office or consents for treatment of the minor will be the responsible party on the account and is responsible for all

charges regardless of divorce, separation, or court decree. We request patients age 18 or older covered under their parents

insurance to sign an authorization allowing Ear, Nose & Throat Associates, PC to contact parents regarding insurance and billing

issues.

Father’s Name ______________________________ Cell Phone # ___________________ Work Phone#_________________

Mother’s Name______________________________ Cell Phone # ___________________ Work Phone#_________________

Optional Consent:

In the event that a parent cannot bring the minor patient to an appointment, I give consent for Ear, Nose & Throat Associates to

evaluate and treat the minor patient in my absence, under the supervision of the following adult(s):

_______________________________________________ Relationship to patient: ___________________________

I understand that this person will be required to provide a photo ID for verification. I understand I am responsible for all charges

incurred on behalf of the patient, and am aware that fees are due at the time of service. If this section is not completed in our office,

it must be notarized for this consent for treatment to be utilized.

I hereby give consent for evaluation and treatment of:

(Full Legal Name of minor patient):_____________________________________________________________________

Signature of Parent or Legal Guardian_________________________________________ Date_____________________

Witnessed in the ENT / WHC office by_________________________________________ Date_____________________

Otherwise:

Notary Acknowledgement: This instrument was acknowledged before me on ________________________ (date)

Signature of Notary Public _______________________________________

My Commission Expires: ________________________

(Notary Seal)

Minor Patient Treatment Consent Form