Fillable MINOR CONSENT FOR MEDICAL SERVICES (For use with (California State University, Sacramento)

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MINOR CONSENT FOR MEDICAL SERVICES (For use with (California State University, Sacramento)

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S:SHC Intranet\Forms\General-Administrative Forms | Minor Consent – Medical & Counseling Services | 9.2018
MINOR CONSENT FOR MEDICAL SERVICES
(For use with Students 17 years of age and younger, as applicable)
I hereby authorize Sacramento State Student Health & Counseling Services to provide, at the request of my
Minor son/daughter
Medical services, as needed. I further
authorize any necessary emergency care in the event that I cannot be reached to give direct permission.
Parent/Guardian Signature
Date
** PLEASE PRINT **
Minor’s Name:
Date of Birth:
Parent/Guardian:
Address/State/Zip:
Phone Number:
Emergency Contact:
Phone Number:
Relationship:
List of Medical Conditions:
Allergies:
FOR OFFICE USE ONLY
Telephone Consent
Parent/Guardian consent given: Yes No Date/Time of Consent:
Method of Verification of Identity: (Check all that apply)
Call at workplace
Parent/Guardian CDL:
Gave student’s date of birth as:
No minor consent required for Reproductive Health Services
Staff Signature/Title
Date/Time
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MINOR CONSENT FOR MEDICAL SERVICES (For use with (California State University, Sacramento)

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Completed 28 January 2021

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