Minor Consent Form

Consent to Medical Treatment of a Minor

Allergy & Asthma Associates of Allen
977 Raintree Circle, Ste 100, Allen, Texas 75013
Phone: (972) 747-7007 | Fax: (972) 747-7006 | www.allenallergy.com

Consent to Medical Treatment of a Minor

Complete and submit this form once. All answers are sent together in a single email.

Consent to Medical Treatment of a Minor

To Whom It May Concern: I hereby give permission for Allergy & Asthma Associates of Allen to examine and treat my child.

Patient’s Name (Minor)

Age (years)

Date of Birth

Guardian 1

Guardian Name

Relationship

Cell Number

Guardian 2 (optional)

Guardian Name

Relationship

Cell Number

Individual over age 16 AUTHORIZED to bring the patient for injections

Authorized Person Name

Relationship

Cell Number

I further give my permission and consent to the physicians, nurses, and staff of Allergy & Asthma Associates of Allen to administer any medical treatment sought by me on the minor’s behalf.

Signature

Date

Signature (type full legal name)

Relationship to Minor

Mother Father Guardian

I confirm I am authorized to consent to medical treatment for this minor and the information above is accurate.