Loading
Medical Consent Form for Minors
PARENT OR GUARDIAN INFORMATION
Parent's/Guardian's Full Name
Date
CHILD INFORMATION
Child's Full Name
Date of Birth
I, , am the legal parent or guardian of the minor child, , born on . I hereby authorize and consent to any necessary medical treatment, including diagnostic procedures, surgery, and administration of medication, as deemed necessary by VitalCare Medical Associates for the well-being of my child.
In the event of an emergency or if I cannot be reached, I authorize VitalCare Medical Associates and its staff to make decisions on my behalf regarding my child's medical treatment. This authorization includes the release of medical records to other healthcare providers as needed for continuity of care.
I understand that VitalCare Medical Associates will make reasonable efforts to contact me before any non-emergency medical treatment is administered to my child. However, in the case of an emergency where immediate treatment is necessary, I give my consent for such treatment without prior notification.
I acknowledge that I am responsible for any costs associated with medical treatment for my child and that such costs are not the responsibility of VitalCare Medical Associates.
This consent is effective from 2024-08-02 and will remain in effect until 2024-09-01, unless earlier revoked by me in writing. I understand that I have the right to revoke this consent at any time by providing written notice to VitalCare Medical Associates.
In case of any questions or concerns, you may contact me at .
I have read and understand the contents of this Medical Consent Form, and I willingly give my consent for medical treatment for my child.
Parent/Guardian Signature *
Date Signed *
Witness Name
Date *
FOR MORE INFORMATION: