• Designation of Consent for Another to Authorize Treatment

    Spectra Health Clinics

  • It is best practice to see minors with their parent or authorized guardian present. If you cannot be present at the appointment with your minor, we are legally obligated to have your written authorization before we treat your minor.

    This form allows you to pre-designate adults who can accompany your minor at future visits and consent to treatment for your minor by exercising their own best judgement upon advice of Spectra Health licensed personnel.

    Our clinic staff and providers reserve the right to postpone any non-urgent procedure if proper consent cannot be obtained before the time of an appointment.

     

    NOTICE: This form must be completed by the minor patient's parent or legal guardian.

  • Minor Patient's Information

  • Minor Patient's Date of Birth*
     - -
  • minor's dob print*
     / /

  • Parent/Legal Guardian's Information

  • Parent/Legal Guardian Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • guardian dob print*
     / /
  • The authorized guardian for this minor is a representative of a government agency:*
  • Format: (000) 000-0000.
  • Add an additional parent or legal guardian to this authorization?*
  • Additional Parent/Legal Guardian Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • addtl guardian dob print*
     / /

  • Designation of Authorized Adults

  • Minors under 14 years of age must be accompanied to appointments by a parent, authorized guardian, or designated adult.

    In this section of the form, you may designate any other adults who can accompany the minor patient to an appointment. 

    • These individuals will be able to authorize treatment on your behalf.
    • The authorized individuals you list must be over the age of 18.

  • Minors over the age of 14:

    If the minor patient is over the age of 14, you may choose to allow them to attend appointments without a parent, a legal guardian, or another approved designated adult.

  • This minor patient is over the age of 14 and I am choosing to allow them to attend appointments without a legal guardian or authorized adult present:*
  • Can accompany minor to visit?*
  • Format: (000) 000-0000.
  • Do you wish to add another authorized adult to accompany your minor to appointments at Spectra Health?*
  • Can accompany minor to visit?*
  • Format: (000) 000-0000.
  • Do you wish to add another authorized adult to accompany your minor to appointments at Spectra Health?*
  • Can accompany minor to visit?*
  • Format: (000) 000-0000.
  • Do you wish to add another authorized adult to accompany your minor to appointments at Spectra Health?*
  • Can accompany minor to visit?*
  • Format: (000) 000-0000.

  • Dental Extraction Authorization

  • This section only needs to be completed if the minor patient will be treated at Spectra Health Dental Clinic.*

  • Dental Clinic - Extraction Appointments:

    Due to the irreversible nature of extractions, a parent or legal guardian must be present for all extraction appointments involving the minor patient, and no other adult can be designated to authorize this treatment or attend these visits.

    Minor patients between the ages of 14 and 18 must be accompanied by their parent or legal guardian during extraction visits.  Any designated authorized adults listed above are not allowed to authorize extractions, nor attend these visits.

  • Date
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  • Treatment Plan Consent:

    Dental treatment at Spectra Health Dental Clinic will be completed as listed and described on a patient's treatment plan.  Treatment plans must be authorized by a parent or legal guardian.  Treatment plans must be signed separately from this consent form.

  • Limitations on Treatment

  • During appointments where the minor patient is not accompanied by a parent or legal guardian, you may choose to place limitations on the care that any designated authorized adults may consent to (or, your minor patient, in the case of minors above the age of 14).

  • Are there any limitations you would like to place on the treatment that Spectra Health may provide to your minor if a parent or legal guardian is not present?*

  • Parental/Legal Guardian Consent

  • In an emergency, we will provide treatment and contact you as soon as possible. Urgency will be determined by our licensed professionals. Be advised that your minor's protected health information may be shared with the person(s) you designate on this form to accompany your minor to appointments. If you do not want protected information shared with the authorized adults listed on this form, please disclose this in the limitations section above.

    I have the legal right to pre-authorize Spectra Health to deliver health care to my minor, listed above. I request and authorize Spectra Health and its personnel to deliver health care to my minor, listed above. I understand that every effort will be made to obtain proper consent prior to each visit. I understand that in an emergency situation, treatment for my minor will be initiated immediately and Spectra Health personnel will contact me as soon as possible. I understand that I am providing authority to the designated adult(s) to consent to treat my minor and exercise his or her own best judgement upon the advice of licensed Spectra Health personnel. The information provided on this form is true, correct, and complete to the best of my ability.

     
  • Date
     / /
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