Medical Consent Form for Minors
Minor's Information
Full Name
Date of Birth
Address
Parent / Legal Guardian Information
Full Name
Relationship to Minor
Phone Number
Email
Emergency Contact
Name
Relationship
Phone Number
Consent
I, the undersigned, authorize medical treatment for the minor named above if I cannot be reached in an emergency.
I give my consent
Medical Information
Known Allergies
Medications Currently Taken
Relevant Medical Conditions
Additional Instructions
Parent/Guardian Signature
Date