Minor Consent Form

Minor Consent

Download form here, or complete the form and submit below.

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:

I also authorize and give consent to SCCIM providers and staff for medical evaluation and treatment of my child if a parent or legal guardian is not present.

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 *

YYYY

Name of Minor *

First Name

Last Name

Minor's Date of Birth *

YYYY

Name of authorized individual giving consent *

First Name

Last Name

Relationship to Minor *

Phone

(###)

###

####