Consent for Treatment of a Minor Child

Little Traverse Bay Bands Health Center
1260 Crane Ave
Petoskey, MI 49770
Phone: (231) 242-1700 Fax: (231) 242-1717

Consent for Treatment of a Minor Child

I, (Parent/Guardian name), give LTBB of Odawa Indians Health Department permission to treat my child, (Child's name), while I am not present. The individual bringing my child to the appointment(s) is named: (Adult accompanying child) and is at least eighteen years of age.

Parent/guardian name:

Child's name:

Child's Date of Birth:

Adult accompanying child:

I also give this individual permission to make decisions regarding my child’s
medical/dental treatment in consultation with the providers and/or if an emergency
should arise while at the LTBB Health Department.

Authorization:

Parent/Legal guardian name:

Phone number:

Address:

This authorization shall be in effect until:

Effective end date:

Signature of parent/guardian:

clear

Date: