Authorization for treatment of a minor/Adult with Guardian
My signature below attests that I am the ___ Biological/Adoptive Parent for the following patient:
___ Legal Guardian; or
___ Foster Parent
____________________________________
__ __ / __ __ / __ __ __ __
(Patient DOB)
(Name of Patient)
This authorization includes all necessary treatment and administration of vaccinations as determined by the treating
provider (foster parents may only give consent for routine health care as defined in form DPP-106A from
the Cabinet for Health and Family Services). By signing this form, I understand that as of the age of sixteen
years, there are certain areas of care my child may seek treatment for without my permission.
FOR BIOLOGICAL/ADOPTIVE PARENTS ONLY –You may list in the space provided below individuals
who are given permission to consent for treatment for the above-listed patient and have the same access to the
patient’s medical records, including the right to disclose the contents to others:
Authorized Individuals:
Relationship to Patient:
______________________________
______________________________
________________________________
________________________________
FOR MINOR PATIENTS 16 YRS. OF AGE OR OLDER-I authorize the above-referenced minor patient to
seek care and treatment without a parent/guardian present.
______________________________
Signature of Parent/Guardian
________________________________
Relationship to Patient
I further consent for copies of this minor’s immunization records to be released as needed to the following
schools/daycares: _____________________________________________________________________
In order to protect the welfare of the patient, if any court orders/decrees/letters/contracts authorizing medical
treatment exist regarding custodial/parental/guardian rights, etc., please be aware that we need to have a copy of
these documents in the patient’s file.
I understand that I may be subject to legal ramifications if I purposely provide false or inaccurate information to
White House Clinics. This release expires one (1) year from the date of signature; unless I choose to revoke this
agreement (termination of the authorization must be received in writing).
___________________________________
________________________________
Signature of Parent/Guardian
Relationship to Patient
___________________________________
________________________________
Signature of Witness
Date