Consent for Medical Treatment of A Minor

"*" indicates required fields

Minor / Child Information

First Name*

Last Name*

Birth Date*

Parent / Legal Guardian Information

First Name*

Last Name*

Relation to Child*

Consent

I am the parent or legal guardian of the minor child listed above and I give the following consent for their treatment:

I give permission for them to receive medical treatment by the providers and staff of Bluegrass Allergy Care.

I give permission for them to come inside the building without an adult to receive allergy injection(s)s, but I understand an adult must be on the premises at the time of the allergy injection(s)s given.

I give permission for my 16 or 17 year-old to receive allergy injection(s) unaccompanied by an adult.

I give permission for designated adults to attend physician appointments and allergy injections (if applicable) with my child in my absence and agree to update the list of designated adults as necessary. Please note that designated adults will need to bring photo identification with them at time of treatment.

Designated Adult 1

First Name*

Last Name*

Relation to Child*

Add 2nd Adult

Add Another Designated Adult

Designated Adult 2

First Name*

Last Name*

Relation to Child*

Add 3rd Adult

Add Another Designated Adult

Designated Adult 3

First Name*

Last Name*

Relation to Child*

Add 4th Adult

Add Another Designated Adult

Designated Adult 4

First Name*

Last Name*

Relation to Child*

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