Health Services Minor Consent Form printable pdf download

Health Services Minor Consent Form

PARENT

SACRED HEART UNIVERISTY

WELLNESS CENTER/HEALTH SERVICES

MINOR CONSENT FORM

UNDER THE AGE OF 18

I _________________________________________________________, do hereby grant permission to

Parent or Legal Guardian (print)

Sacred Heart University Health Services and its personnel to administer such treatment to

my son/daughter ________________________________________________________

Student (print)

Student ID #____________________________

Date of Birth_________________________

that are medically advisable or appropriate in the opinion of the treating provider, when need of immunizations, treating

minor medical illnesses or minor injuries.

I also grant permission to the Student Health Service to take such actions with respect to my son/daughter that are

customary or appropriate in connections with his/her care, including administering routine lab services such as blood

counts, urinalysis, ordering x-rays and the prescription of medications necessary and appropriate in the treatment of

his/her condition .

I understand that in cases of emergency and/or when referral is necessary for major medical illnesses or injuries, the

Student Health Service will obtain my consent through the telephone. I also understand that in such cases where the

Student Health Service has been unable to contact me, and in the provider’s opinion a delay in initiation or provision of

treatment would endanger the health or physical well-being of my son/daughter, the Student Health Service will render

the necessary emergency medical care to my son/daughter without my consent.

Signature:_____________________________________________________ Date:______________

Mother, Father, or Legal Guardian

Relation to Student: _________________________________________________________________

Address:___________________________________________________________________________

__________________________________________________________________________________

Allergies:__________________________________________________________________________

Home Phone#_______________ Work Phone#________________ Other Phone#_________________

April 23, 2015

Health Services Minor Consent Form