Fillable Form 1: CONSENT TO TREAT MINOR CHILD PARENT/GUARDIAN (University of North Dakota)

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Form 1: CONSENT TO TREAT MINOR CHILD PARENT/GUARDIAN (University of North Dakota)

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SHS FORM #125
06/02/11
Medical Record #________________
CONSENT TO TREAT MINOR CHILD
1
– PARENT/GUARDIAN AUTHORIZATION
Patient/Student Information
Patient/Child Name: ___________________________________________________________________________________
Local Address: _________________________________________________________________________________________
City: _______________________________ State: __________________________ Zip Code:________________________
Local Phone: ____________________________ W:_________________________ Cell: _____________________________
Date of Birth: ________/_________/19_______ UND ID# ____________________________________________
Parent/Guardian Complete the Following
I grant the University of North Dakota Student Health Services healthcare providers, and other
licensed healthcare staff, permission to provide routine, emergency, or urgent care and
treatment, for my child should medical attention be necessary while my child is enrolled at the
University of North Dakota. I further give healthcare staff permission to contact my child’s
primary healthcare provider regarding past medical and medication history, if necessary.
_______________________________________________________________ _____________________________________
Parent/Guardian Relationship to Student
(Print)
_______________________________________________________________ ______________________________________
Parent/Guardian Date
(Signature)
Parent Address:________________________________________________________________________________________
City: ___________________________________ State: _________________________ Zip Code:______________________
Phone: (H) _______________________________ (W) __________________________ (Cell) _________________________
Comments:
1
A minor is defined as any student/patient who is under the age of 18. Exceptions to this are made in circumstances
in which North Dakota State Law allows minors to seek certain healthcare services without parental consent.
John A. Swenson Student Health Services
McCannel Hall, Room 100
2891 2
nd
Avenue N., Stop 9038
Grand Forks, ND 58202-9038
Phone: 701.777.4500 Fax: 701.777.4835
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Form 1: CONSENT TO TREAT MINOR CHILD PARENTGUARDIAN (University of North Dakota)

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Completed 2 February 2021

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