In order for us to treat a minor without a parent/legal guardian present, please complete this form and return it with a copy of the parent/legal guardian driver license or state issued identification to Midlothian Medical and Sports Center.
I authorize Midlothian Medical and Sports Center to provide treatment per the signed treatment consent form to my son/daughter as deemed appropriate by the provider.I further understand once my child reaches the age of eighteen (18) my consent for treatment is no longer needed.This consent will remain in effect until the patient reaches the age of eighteen (18) unless revoked in writing to Midlothian Medical and Sports Center.By signing this, I acknowledge I have read and agree to this consent and that any questions I had prior to signing were answered by Midlothian Medical and Sports Center.Payment is expected the day of the appointment and can be made by cash, check, or credit card during check out.
In the event we need to contact you in regards to please provide your best contact information.
