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.

, 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)

, to hereby confer upon

(Name of Person Bringing Minor for Care)

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

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

1. Name:
Date of Birth (dd/mm/yyyy):
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

Date (dd/mm/yyyy)

Parent or Guardian Signature (please print)

Address of Parent or Guardian

Home and Work Phones of Parent or Guardian

Witness Signature

Date (dd/mm/yyyy)

American College of Radiology

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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 160 convenient locations across 11 states and provides late night and weekend appointments to accommodate patients.

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