Consent to Treat a Minor, English

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To Parents and Guardians of Minor Children

The providers and staff of Pediatric & Adolescent Medical Associates of the Pacific Coast, Inc. (Pacific Coast Pediatrics) place great emphasis on the health and well-being of each and every patient in our clinic. We appreciate that you have entrusted us to provide health care services to your minor child and we look forward to working with you to ensure that your child receives the best health care possible.

As a general rule, we require the consent of a parent or legal guardian in order to provide health care services to a minor child (someone under the age of 18). With so many parents working outside the home or with other commitments, we realize that you may not be able to accompany your child on every visit to the clinic. If your minor child presents to the clinic unaccompanied, we will not be able to see the unaccompanied minor. If the minor presents in the company of an adult other than a parent or legal guardian, they must have documentation from the parent or legal guardian giving consent for treatment. If they do not have consent for treatment the appointment will be rescheduled.

In an effort to provide the care needed and avoid having to reschedule your child’s appointment, we have developed a Consent to Treat a Minor form that, once completed by a parent or legal guardian, will be placed in your child’s medical record for use as necessary. This form will allow us to provide routine and emergency medical treatment for your minor child when deemed necessary by qualified medical personnel. Adults, other than the parent or legal guardian who accompany a minor child to an appointment and are authorized by the Consent to Treat a Minor on record, will be asked to present photo ID upon checking the patient in for the appointment. This consent form will remain in effect until revoked in writing. You may request this form from any member of our clinic staff.

By law, minors have the right to consent to certain health care without a parent or guardian’s consent. A minor may consent to medical:

If the minor is emancipated (legally independent) or married to someone at or above age 18
In the event emergency care is necessary
For birth control and pregnancy-related care at any age
For outpatient drug and alcohol abuse related treatment beginning at age 12
For outpatient mental health treatment beginning at age 12
For sexually transmitted diseases, including HIV, beginning at age 12

If a minor consents to care as allowed by law, he or she can request confidentiality for that aspect of care which would prohibit us from releasing this information to anyone, including a parent or guardian, without the minor’s express written permission.

It is the philosophy of this clinic to encourage minor patients to include a parent, guardian or other trusted adult in all aspects of their health care including those areas noted above. For legal and other reasons, parent or guardian involvement may not always be possible. Rest assured that we would continue to provide health care services that are in the best interests of your minor child. If you have questions regarding any of this information, please contact your child’s primary care physician.

Patient Name*

Date of birth*

I, the undersigned, parent(s) or legal guardian of the above named patient, a minor, do hereby authorize the physicians at Pediatric & Adolescent Medical Associates of the Pacific Coast, Inc. (PAMA) to act as agent(s) for the undersigned to consent to physical examination, medical diagnosis and treatment or other medical care which is deemed advisable by, and is to be rendered under the general or special supervision of, the treating physician who is licensed to practice in the state of California, whether such diagnosis or treatment is rendered at the office of said physician or at any hospital. I further acknowledge that I am responsible for any portion of charges that are not covered by the child’s insurance.

In an emergency, it is understood that authorization is granted to the physicians at PAMA in advance of any specific diagnosis, treatment or hospital care rendered to the above named patient. Authorization is granted to provide authority and power on the part of the physicians to provide all such medical or surgical diagnosis, treatment or hospital care which the aforementioned physician(s), in the exercise of his or her best judgment, may deem advisable.

Consent to Treat a Minor Child accompanied by an adult other than the child’s parent or legal guardian

I, the parent or legal guardian of the patient named above, do hereby authorize the physicians at PAMA to perform medical treatment as per the statements above when accompanied by either of the following named adult persons over the age of 18:

Adult’s name*

Relationship to the child*

(Grandparent, Aunt, Uncle, Sister, Brother, Family Friend)

Adult’s name

Relationship to the child

(Grandparent, Aunt, Uncle, Sister, Brother, Family Friend)

Consent to Treat a Minor*

For any and all medical treatment including preventative care, school/sports physicals & vaccines

Today’s visit only, date

For this specific problem(s) or a specific date range. Please specify

Specific problem(s) or a specific date range

This consent will be valid until revoked in writing by me from the date signed unless otherwise specified in writing.

Parent/patient or legal guardian name*

First Last

Date

Signature*

Consent to Treat a Minor, English

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