Revision 2.14.2020 Y:\1 Ilanka – GENERAL\FRONT DESK FORMS\Legal Forms\Treatment of Minors Consent
Ilanka Community Health Center
705 Second Street – PO Box 2290
Cordova, AK 99574
Ph: 907-424-3622 Fax: 907-424-3275
CONSENT TO TREAT
I, _______________________________, give consent to Ilanka Community Health Center to provide
treatment and/or necessary procedures to my minor child.
__________________________________________________________________________
Child’s Name Date of Birth
________________________________________________ _________________
Parent/Guardian Printed Name Date
________________________________________________ _________________
Parent/Guardian Signature Date
This authorization is valid:
For a limited time. From __________________ to ___________________
(date) (date)
Ongoing until withdrawn
I authorize the following adults to accompany this minor child noted above to seek and obtain medical
care and treatment from Ilanka Community Health Center:
___________________________________________ ________________________
Name Relationship to Child
___________________________________________ ________________________
Name Relationship to Child
__________________________________________ ________________________
Name Relationship to Child
I understand that I am authorizing the above named adults the ability to make medical decisions for my
child on my behalf, in my absence. I further understand that I remain the financially responsible party
for my child’s medical care.
________________________________________________ _________________
Parent/Guardian Signature Date
