Minor Consent


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Consent for Treatment of Minors
I hereby authorize and give consent to South Carolina Center for Integrative Medicine (SCCIM) providers and staff to evaluate and treat my child. This permission includes treatment, minor procedures, injections, and prescriptions written. SCCIM providers and staff prefer that all minors seeking treatment be accompanied by a parent/legal guardian for the first visit. After the initial appointment, a minor may be seen at SCCIM for treatment without the parent/legal guardian present if this consent is complete and box is checked below:
This authorization must be completed annually until the minor is 18 years of age. Authorization and consent to medical treatment of minors is also under the jurisdiction of state and federal laws, and special requirements or exceptions to parental consent may apply.
Today's Date *
Today's Date
Name of Minor *
Name of Minor
Minor's Date of Birth *
Minor's Date of Birth
Name of authorized individual giving consent *
Name of authorized individual giving consent
Phone Number
Phone Number