Minor Consent Form (English)

Medical Consent form for Minor Children

A signed Medical Consent form is required when a child of 14 years or younger is in need of medical care and the child is accompanied by an adult who is NOT the child’s parent or legal guardian. I,(Required)

hereby authorize(Required)

to bring my minor child(Required)

DOB(Required)

to West Hills Healthcare Clinic for the purpose of: (Please check each item you are authorizing)

General office visit and treatment

Immunizations and/or injections (including possible antibiotic injection)

Labs deemed necessary by your child’s provider (which may or may not require a blood draw)

Procedures (Such as wart removal, ingrown toenail procedure, etc)

Current Medications

Known Allergies

Signature of Parent or Legal Guardian(Required)

Date(Required)

Best contact phone number for Parent/Legal Guardian

West Hills Healthcare Clinics participation in Comprehensive Primary Care Plus (CPC+) is ending. Beginning in 2022 we will be participating in a new program to enhance your care, Primary Care First.