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Consent for Treatment of Minor Patients

Consent for Treatment of a Minor

TREATMENT TO MINORS

Many times parents find themselves unable to accompany their teen or young adult children to appointments. This form has been prepared for your convenience should you at some time be unable to accompany your child.

I hereby grant TED RUDOLPH, M.D and/or his staff permission to treat my child, _______________________________ , when they arrive at the office unaccompanied by their parent or guardian.

Signature of Patient/Guardian

Prefer to fill this out by hand? Download a blank copy to print and bring with you.

Download the blank Treatment of Minors Form (PDF)