Authorization for Treatment of Unaccompanied Minor Children

Authorization for Treatment of Unaccompanied Minor Children
General Consent to Evaluate and Treat Unaccompanied Minor
I, name of parent/legal guardian authorize One Community Health to treat my minor child, name of minor when unaccompanied, for routine and emergency medical treatment.
EXCLUSIONS: Minor medical procedures (i.e. wart, mole, or toenail removal, etc.).
If your child is scheduled for a well child check and/or sports physical during the visit – in addition to this form, you will also need to fill out the Health History Questionnaire and the OSAA Pre-Participation Sports Physical Exam Questionnaire

• I UNDERSTAND that both the Unaccompanied Minor Authorization, Health History
Questionnaire and the OSAA Pre-Participation Sports Physical Exam Questionnaire
are required in order to complete a Well Child/Adolescent Visit and/or Sports Physical. If not completed, the patient will be rescheduled.
Consent to Vaccinate Unaccompanied Minor

I authorize One Community Health to provide vaccines to my minor child, when unaccompanied, according to the routine childhood immunization schedule.I DO NOT authorize One Community Health to provide vaccines to my minor child, when unaccompanied, according to the routine childhood immunization schedule.
If your child will be receiving immunizations during the visit – in addition to this form, you will also need to fill out the Child and Teen Immunization Screening Form.

• One screening form is required for each immunization visit, every time immunizations are given.

• I UNDERSTAND that both the Unaccompanied Minor Authorization, and the Child and Teen Immunization Screening Form are required to administer immunizations to an unaccompanied minor. If not completed, the patient will not receive vaccinations during their visit.
This authorization will automatically expire in one year from date signed below unless you wish it to expire sooner. If so, enter date:
MM/DD/YYYY.
- I UNDERSTAND I must have an existing, valid phone number on file in my minor child’s chart for verification and contact purposes.
- I UNDERSTAND that I can select either or both of the options listed above.
- I UNDERSTAND that I may revoke this request in writing. If revoked, it would not affect any actions already taken by One Community Health based upon this authorization.
Name of parent/legal guardian

First NameLast Name
Signature

Clear
Todays Date

MonthDayYear
Date
Should be Empty:

Authorization for Treatment of Unaccompanied Minor Children

General Consent to Evaluate and Treat Unaccompanied Minor