Sacred Heart University Minor Consent Form
Submit completed form by uploading to the Student Health Portal - myhealth.sacredheart.edu
Student Last Name
Student First Name
Date of Birth
Student Health Services Minor Consent Required only if student will be under age 18 at the start of classes
Consent for Treatment of a Minor:
I hereby grant permission to Sacred Heart University Student Health Services and its staff to provide my son/daughter (named above) with
appropriate medical care including treatment of illnesses/injuries, immunizations, prescription of medication, and any other treatments
that are medically advisable or appropriate in the opinion of the treating provider. I also grant permission to Student Health Services to
take such actions with respect to my son/daughter that are customary or appropriate in connection with his/her care, including
administering routine lab services such as blood counts, urinalysis, or ordering x-rays in the treatment of his/her condition. I understand
that in cases of emergency and/or when referral is necessary for major medical illnesses or injuries, Student Health Services will obtain my
consent through the telephone. I also understand that in such cases where Student Health Services has been unable to contact me, and in
the provider’s opinion a delay in initiation or provision of treatment would endanger the health or physical well-being of my son/daughter,
Student Health Services will render the necessary emergency medical care to my son/daughter without my consent.
Signature below indicates understanding of and agreement with the above information.
Parent/Guardian Signature: Date:
Parent/Guardian Name (print)
Relationship to Student
Phone #
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