Sacred Heart University – Minor Consent Form
Submit completed form by uploading to the Student Health Portal - myhealth.sacredheart.edu
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)