Excel Minor Consent
Uploaded by
Grayson Carwile CampbellExcel Minor Consent
Uploaded by
Grayson Carwile CampbellExcellent Care. Exceptional Results.
CONSENT TO TREAT MINOR CHILDREN
Please print all information
Being the parent or legal guardian of _____________________________
(minors printed name),
I__________________________(parent/guardians printed name) hereby
authorize Excel Therapy, LLC consent for Physical Therapy evaluation and
treatment effective now or in the future of my minor child, born__________.
Further, as parent or legal guardian, I am responsible for the health care
decisions of my minor child and agree that my insurance plan is the primary
plan to pay for the dental, medical, or hospital care or treatment that is given
to my child.
_____________________________________________________________
Signature of Parent or Legal Guardian
__________________________
Witness Signature
_______________________________
Witness Name (please print)
This consent form should be taken with the child to the hospital or
physician's office when the child is taken for treatment.
This additional information will assist in treatment if it can be furnished with
the consent but is not required.
Family address _________________________________________________
Telephone:
Father ______________ home ________________ work
Mother _____________ home ________________ work
Child's Birth date ________________ Last Tetanus ___________________
Allergies to drugs or foods _______________________________________
_____________________________________________________________
Special Medications, Blood Type or Pertinent Information
_____________________________________________________________
_____________________________________________________________
Child's Physician __________________________ Phone _______________
Insurance ________________________________ Policy # _____________
Preferred Hospital ______________________________________________
