Consent To Treat Minor Form printable pdf download

Consent To Treat Minor Form

CONSENT TO TREAT MINOR FORM

I, _______________________________________, the parent/guardian

of _______________________________________, grant permission for

my above named child to be treated at the Krohn Clinic.

This consent covers the date of _________________(month/day/year). I do hereby

indemnify and hold harmless the physicians and other healthcare workers who act in

reliance with this authorization.

Date: _______________

Parent/Guardian: _______________________________

Time: ______________

Witness: ______________________________________

Verbal Consent

Second Witness:________________________________

Additional Information:

Parent/Guardian can be located at the following phone number/address:

Any allergies and/or medical conditions of child:

Insurance Information:

Insurance: ______________________ Insurance Co. Phone Number _______________

Group Number:__________________ Subscriber Number:_______________________

Child’s Birth Date:_____________________

(Please send a copy of insurance card, if available)

Krohn Clinic Label

03/10/2006

Consent To Treat Minor Form