Indiana University Health Center

600 N. Jordan Avenue

Bloomington, Indiana

47405-3191

 


Consent for Medical Treatment of a Minor

 

Name:                                                                          UID#:                                                    Date:

 

In order to enable the Health Center of Indiana University and/or other health facilities in Bloomington to provide prompt care to your minor son or daughter, we urge you to read and complete this Consent form.  Please return it promptly to Indiana University Health Center, 600 N Jordan Ave., Bloomington, IN 47405, Fax: 812-855-4628.   In this way, we can help your child without delay should an emergency occur.

 

I, ________________________________________,
        (Full name of parent/guardian)

declare that I am the________________________________________
                                                  (Father/Mother/Guardian)

of ______________________________________
                       (Full name of minor)

University ID #_____________________,

a minor, age __________,

born_____________________, 19_____________

Please provide the following information concerning said minor:

Allergic Reactions: ______________________________________________________________________

Present Medication ( if taking, now):_____________________________________________________


Date of Last Tetanus Booster: ________________________________________

Any past illness or other information that would be useful in the event medical treatment is necessary:
________________________________________________________________________________
IN CASE OF EMERGENCY: 

Telephone: (Home) ____________________

 (Work) ____________________     (Cell) ___________________________

Address: ___________________________________________________________________
Please complete ONE of the following:
I grant permission of the Directors, assistants, or other persons responsible for his/her care to act on my behalf for said minor in granting permission for evaluation and treatment of medical or psychological problems.  In the event that I cannot be reached, I hereby give my consent to such medical treatment as deemed necessary, including surgery, lab tests, x-ray examinations and physical therapy to be rendered to said minor by a licensed/certified health care provider.


Date:__________________ Signature:________________________________________ (Parent or Guardian)


I do not wish medical care of any kind except emergency care to be provided for:______________________________

                                                                                                                                             (Full name of minor)
Date:____________________ Signature:___________________________________ (Parent or Guardian)

I authorize limited medical care as follows: __________________________________________________________

to be provided for:________________________________________  (Full name of minor)

Date:____________________ Signature:___________________________________ (Parent or Guardian)