Minor Consent Form | AdventHealth

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CONSENT FORM FOR TREATMENT OF MINOR CHILD

The State of Florida has enacted a new law that imposes additional obligations on health care providers when obtaining consent to treat a minor child.  This form seeks to comply with our obligations under this new law, including obtaining a written consent to prescribe, where medically indicated, medicinal drugs needed by the minor child identified below.  The new law also states that written consent must be obtained from a parent who has legal custody of the minor child or is the legal guardian of the minor child.
By signing below, I represent that I am either a parent with legal custody or the legal guardian of the minor child named below.
I give AdventHealth facilities, physicians, other medical professionals, residents, students, and AdventHealth employees, contractors, and personnel consent to provide, solicit and arrange for health care services, and prescribe medicinal drugs when necessary, to the minor child named below.
THIS CONSENT FORM HAS BEEN EXPLAINED TO ME AND MY QUESTIONS HAVE BEEN ANSWERED.

Where is your child receiving care?*

Physician Office Centra Care Urgent Care Hospital

In what city is your child receiving care?*

Date & Time*

Signature*

[clear]

Use your mouse or finger to draw your signature above

Name*

First Name

Last Name

Relationship*

Name of Minor *

First Name

Last Name

Date of Birth of Minor*

Hospital Form ID

Barcode

PATIENT LABEL

Patient/Minor Name: _________________

DOB:_________________________________

FIN:__________________________________

MRN:_________________________________