Parental Consent

Parental Consent To Treat A Minor Form

The following form is designed for those situations where minors are unaccompanied by either parents or legal guardians. This “Parental Consent to Treat A Minor Form” gives authority to a designated adult to arrange for medical care for a minor. Medical care cannot be provided to a minor without the approval by the parents or legal guardians, unless there is written consent authorizing an agent to give approval. In addition, a copy of the Parent/Legal Guardian photo ID must be provided with consent.

PARENT/LEGAL Guardian:

, am the Parent/Legal Guardian (if Legal Guardian, attach copy of court order) of the child listed below and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.

Name of Parent or Legal Guardian or Custodian

(Name of Parent or Legal Guardian or Custodian)

, to hereby confer upon

Name of Person Bringing Minor for Care

(Name of Person Bringing Minor for Care)

residing at

Residing At

the power to consent to necessary medical or mental health treatment on

Date of Service (mm/dd/yyyy)

(date of service (mm/dd/yyyy))

1. Name:

Minor Name

Date of Birth (dd/mm/yyyy):

Date of Birth (mm/dd/yyyy):

Residing at:

Residing At

The undersigned do hereby authorize the aforementioned as an agent on behalf of the undersigned to consent to treatment provided by SimonMed Imaging for the above named minor.

Parent or Guardian Signature

Parent or Guardian Signature

Date of Birth (mm/dd/yyyy):

Date (dd/mm/yyyy)

Parent or Guardian (please print)

Parent or Guardian Signature (please print)

Address of Parent or Guardian

Address of Parent or Guardian

Home and Work Phones of Parent or Guardian

Home and Work Phones of Parent or Guardian

Witness Signature

Witness Signature

Witness Date (mm/dd/yyyy):

Date (dd/mm/yyyy)

Why Choose Us

SimonMed Imaging and its affiliates have been serving the community for over 30 years. Our mission is to provide best-in class affordable care through the use of advanced technology. We have patient-focused staff and highly trained medical professionals.

SimonMed has over 170 convenient locations across 10 states and provides late night and weekend appointments to accommodate patients.