Healthcare Teen Consent Form

HEALTHCARE TEEN CONSENT FORM

Patient Information

Date of Birth:    Age:    Gender:

Emergency Contact

Relationship:    Phone:

Parent / Legal Guardian (if applicable)

Relationship to Patient:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

Immunizations up to date: Yes No

Consent for Services

I hereby authorize licensed clinicians, medical practitioners, nurses and authorized staff of the facility to provide medical care, diagnostic testing, procedures, and counseling as deemed necessary for the health and well-being of the patient named above. This authorization includes, but is not limited to, the services checked below:

General medical examination and treatment
Laboratory tests (blood, urine, swabs)
Immunizations and vaccinations
Mental health evaluation and counseling
Sexually transmitted infection testing and treatment
Contraceptive counseling and services
Telehealth services when appropriate

Risks and Benefits: The proposed services carry potential benefits and risks. Benefits may include diagnosis, treatment, prevention, and improved health outcomes. Risks vary by procedure and may include infection, allergic reaction, adverse response to medication, or emotional discomfort. Clinicians will discuss significant risks and alternative options as appropriate prior to care.

Right to Withdraw: The patient or parent/legal guardian may revoke this consent at any time, except to the extent that action has already been taken in reliance on this consent. Revocation must be provided in writing to clinic personnel.

Emergency Care: In the event of an emergency in which delay would be detrimental to the patient’s health, I authorize emergency medical care and transport as deemed necessary.

Authorization to Release Information & Privacy

I authorize the release of medical information and records related to the services provided under this consent to the persons listed below and to insurance payers as necessary for billing and treatment coordination. I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights with respect to confidential health information.

Consent to Communication: I consent to the clinic leaving appointment reminders or medical information on voicemail or text message at the numbers listed, and I understand messages may contain limited medical information.
Consent to voicemail/text communication

This authorization will expire on: unless earlier revoked in writing.

Certification and Legal Attestation

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I further certify that I am the patient named above and am authorized to consent to these services, or that I am the parent or legal guardian of the patient and have authority to provide consent. I understand that knowingly providing false information or misrepresenting my authority may subject me to legal penalties.

I acknowledge that certain services provided to minors may be subject to confidentiality protections under applicable law. When a minor is permitted to consent independently, treatment may be provided without parental notification unless required or permitted otherwise by law or by the clinical judgment of the provider.

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