Treatment of Minors Form

MEDICAL RESPONSIBILITY

We understand that there will times that a parent will be unable to attend a visit with a child who is under the age of eighteen. We strive to provide quality health care to our younger patients while balancing patient needs and our medical responsibilities.

CHILDREN 0-15 YEARS

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If a parent or guardian is unable to accompany their child to an appointment, then another authorized and responsible adult must accompany them. The parent or guardian must complete and send in a Permission to Accompany a Minor Form with the full name of the responsible party. We will need to see an ID from the accompanying individual. The parent must also agree to be contacted by phone during the exam by the provider or provider's representative. If permission from a parent cannot be obtained, the child cannot be seen.

CHILDREN 16-18 YEARS

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Patients between 16-18 years may be seen without a parent. However, the parent or guardian must complete a Permission to Treat a Minor Form. The parent must also agree to be contacted by phone during the exam by the provider or the provider's representative. If permission from a parent cannot be obtained, the child cannot be seen.