Minor Patient - Parent/Guardian Consent to be Accompanied by Designated Adult

Please fill out all sections of this form to authorize a designated adult to accompany your minor child to medical appointments.

Minor Patient Information

First Name of Minor

Last Name of Minor

Date of Birth (MM/DD/YYYY)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Information

Parent/Guardian Full Name

Relationship to Minor

Phone Number

Email Address

Designated Adult Information

Full Name of Designated Adult

Relationship to Minor

Phone Number

Email Address

Authorization

I, the undersigned parent/legal guardian of the minor listed above, hereby authorize the designated adult to accompany my child to medical appointments at St. Cloud , Ear, Nose and Thorat Clinic. This authorization includes the ability to:

Attend and participate in discussions with healthcare professionals.
Receive instructions regarding medical care and follow-up.
Make decisions on behalf of the minor regarding treatment as recommended by the healthcare provider.

This consent remains valid for one year OR I revoke this authorization in writing.

Acknowledgement and Signature

I acknowledge that I am the legal parent/guardian of the minor patient and that I have the authority to make decisions for the minor patient. I understand that I may revoke this consent at any time by providing written notice to the healthcare provider.

Parent/Guardian Signature (Print Full Name)

Date

Name 2Email 2

Minor Patient – Parent/Guardian Consent to be Accompanied by Designated Adult

Minor Patient Information

Parent/Guardian Information

Designated Adult Information

Authorization

Acknowledgement and Signature

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