Minor Consent (English) – Sugarloaf Pediatrics

Permission to Treat Minor without a Parent/Guardian Present

This form gives us legal permission to treat your child in case you cannot accompany him/her to the clinic
for treatment. Consent may include, but is not limited to clinic visits, medical treatment, immunizations,
and tests.

Patient Name

Date of Birth

Parent/Guardian’s Name

Name of the Person to be Authorized

“I hereby authorize the above person to act on my behalf as an agent to give consent to any medical treatment by the physicians at Sugarloaf Pediatrics. I acknowledge that it is my responsibility to supply all necessary forms and information pertaining to the visit. I am responsible for all reasonable charges in connection with care and treatment.”

This authorization shall remain effective until revocation in writing by the undersigned.

Permission to Treat Minor without a Parent/Guardian Present

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