Patient forms

Authorization to treat a minor

If a grandparent, relative or caregiver may bring your child in when you can’t, authorize them here so we can treat your child without delay.

The child

First name *

Last name *

Date of birth *

Parent or legal guardian

First name *

Last name *

Relationship to the child *

Phone *

Adults you authorize

Authorized adults *

They may consent to *

Sick and urgent care visitsRoutine and well-child visitsAllergy testing and allergy shotsLab tests

Authorization valid until *

Up to one year from today.

Signature

Authorization

As the child’s parent or legal guardian, I authorize the adults named above to consent to the care selected for my child at V-Care Family Practice & Urgent Care until the date above. I can revoke this authorization in writing at any time.

I have read and agree*

Type your full legal name to sign *

Fields marked * are required.

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