Macomb Physicians Group, PLLC, must receive permission from a minor’s parent or legal guardian before providing
treatments for an injury or illness that is non-life threatening. This form gives legal permission to treat the minor in
case the parent/legal guardian cannot accompany him/her to the office for treatment. If the party accompanying the
minor (baby-sitter, friend, relative, etc.) does not present this information, the office will attempt to contact the
parent/legal guardian to request permission to treat the minor.
Please Note:
- A parent/legal guardian must attend a minor’s first visit at Macomb Physicians Group.
- Minor’s may not receive immunizations without a parent or legal guardian present.
- This “Permission to Treat a Minor” form is valid only for the dates listed below.
- In certain circumstances, in accordance with State and Federal laws, parent/legal guardian permission may not be needed for adolescents being seen for concerns of “heightened sensitivity” such as STD testing, family planning, pregnancy, etc.
(print the name of the adult into whose care, the minor has been entrusted) to arrange for and authorize routine and
emergency treatment at Macomb Physicians Group, PLLC for the following dates:
(these dates indicate when this form is valid).
We/I are authorizing the minor to seek and consent to treatment with no adult present.
We/I acknowledge that we are responsible for all reasonable charges in connection with the care and treatment
rendered.
