{"id":53,"date":"2022-01-24T13:32:54","date_gmt":"2022-01-24T13:32:54","guid":{"rendered":"https:\/\/simonmed.wpengine.com\/?page_id=53"},"modified":"2022-09-30T10:48:29","modified_gmt":"2022-09-30T10:48:29","slug":"parental-consent-to-treat-a-minor","status":"publish","type":"page","link":"https:\/\/www.simonmed.com\/patient-info\/parental-consent-to-treat-a-minor\/","title":{"rendered":"Parental Consent To Treat A Minor"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"53\" class=\"elementor elementor-53\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-723fb14f elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"723fb14f\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f8be23f\" data-id=\"f8be23f\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-12b9fe19 elementor-widget elementor-widget-heading\" data-id=\"12b9fe19\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h1 class=\"elementor-heading-title elementor-size-default\">Parental Consent<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a5305cf elementor-hidden-desktop elementor-hidden-tablet elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a5305cf\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-19a9de8\" data-id=\"19a9de8\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-b4a8a61 text-link elementor-widget elementor-widget-button\" data-id=\"b4a8a61\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"\/wp-content\/uploads\/2022\/02\/FM.HIM_.001_Authorization_to_Release_PHI_-_English.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Download PDF<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-62fef4a elementor-hidden-mobile elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"62fef4a\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-23f1fe0\" data-id=\"23f1fe0\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-34b838e elementor-widget elementor-widget-heading\" data-id=\"34b838e\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Parental Consent To Treat A Minor Form\u200b<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f0134bc elementor-widget elementor-widget-text-editor\" data-id=\"f0134bc\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p>The following form is designed for those situations where minors are unaccompanied by either parents or legal guardians. This \u201cParental Consent to Treat A Minor Form\u201d gives authority to a designated adult to arrange for medical care for a minor. Medical care cannot be provided to a minor without the approval by the parents or legal guardians, unless there is written consent authorizing an agent to give approval. In addition, a copy of the Parent\/Legal Guardian photo ID must be provided with consent.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3a545a1 elementor-widget elementor-widget-html\" data-id=\"3a545a1\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t<div class=\"form-wrap\">\r\n\r\n\r\n\t\t<div class=\"center\">\r\n\t\t\t<div class=\"padding-md-h padding-xl-v shift8-padding-xs-v\">\r\n\t\t\t\t\r\n    <div class=\"auth-form patient-info\" data-form=\"2018_patient_information_english\">\r\n\r\n  <div class=\"error-msg\"><\/div>\r\n\r\n  <form class=\"\" id=\"patient-info-form\" name=\"patient-info-form\" data-locale=\"eng\" action=\"#\" method=\"post\">\r\n\r\n    <!-- patient name -->\r\n\t<div class=\"page-part mrgn-top\">\r\n\t\tI,\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"parent-legal-guardian\">PARENT\/LEGAL Guardian:<\/label>\r\n\t\t\t\t<span><input name=\"parent-legal-guardian\" id=\"parent-legal-guardian\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t\t, am the Parent\/Legal Guardian (if Legal\r\n\t\tGuardian, attach copy of court order) of the child listed below and there are no court orders now in effect\r\n\t\tthat would prohibit me from conferring the power to consent upon another person.\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top has-display-below\">\r\n\t\tI,\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"parent-legal-guardian-2\">Name of Parent or Legal Guardian or Custodian<\/label>\r\n\t\t\t\t<span><input name=\"parent-legal-guardian-2\" id=\"parent-legal-guardian-2\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t\t<p class=\"display-below\">(Name of Parent or Legal Guardian or Custodian)<\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t\t, to hereby confer upon\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top has-display-below full-width-field\">\r\n\t\t<div class=\"form-group field field-text\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"person-bringing-for-care\">Name of Person Bringing Minor for Care<\/label>\r\n\t\t\t\t<span class=\"full-width-field\"><input name=\"person-bringing-for-care\" id=\"person-bringing-for-care\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t\t<p class=\"display-below\">(Name of Person Bringing Minor for Care)<\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top left-field\">\r\n\t\tresiding at\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"person-bringing-minor-residence\">Residing At<\/label>\r\n\t\t\t\t<span><input name=\"person-bringing-minor-residence\" id=\"person-bringing-minor-residence\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top inline-field has-display-below\">\r\n\t\tthe power to consent to necessary medical or mental health treatment on\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"date-of-service\">Date of Service  <span>(mm\/dd\/yyyy)<\/span><\/label>\r\n\t\t\t\t<span><input name=\"date-of-service\" id=\"date-of-service\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n\t\t\t\t<p class=\"display-below\">(date of service (mm\/dd\/yyyy))<\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\r\n\t<div class=\"page-part mrgn-top inline-field has-display-below\">\r\n\t\t1. Name:\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"minor-name\">Minor Name<\/label>\r\n\t\t\t\t<span><input name=\"minor-name\" id=\"minor-name\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t\tDate of Birth (dd\/mm\/yyyy):\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"minor-dob\">Date of Birth  <span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n\t\t\t\t<span><input name=\"minor-dob\" id=\"minor-dob\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\r\n\t<div class=\"page-part mrgn-top left-field\">\r\n\t\tResiding at:\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"minor-residence\">Residing At<\/label>\r\n\t\t\t\t<span><input name=\"minor-residence\" id=\"minor-residence\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top\">\r\n\t\tThe undersigned do hereby authorize the aforementioned as an agent on behalf of the undersigned to\r\n\t\tconsent to treatment provided by SimonMed Imaging for the above named minor.\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top inline-field has-display-below\">\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"parent-guardian-signature\">Parent or Guardian Signature<\/label>\r\n\t\t\t\t<span><input name=\"parent-guardian-signature\" id=\"parent-guardian-signature\" disabled=\"\" class=\"form-control sig-width\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t\t<p class=\"display-below align-left\"><em>Parent or Guardian Signature<\/em><\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"parent-guardian-signature-date\">Date of Birth <span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n\t\t\t\t<span><input name=\"parent-guardian-signature-date\" id=\"parent-guardian-signature-date\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n\t\t\t\t<p class=\"display-below align-left\"><em>Date (dd\/mm\/yyyy)<\/em><\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top has-display-below\">\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"parent-guardian-signature-print\">Parent or Guardian (please print)<\/label>\r\n\t\t\t\t<span><input name=\"parent-guardian-signature-print\" id=\"parent-guardian-signature-print\" disabled=\"\" class=\"form-control sig-width\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t\t<p class=\"display-below align-left\"><em>Parent or Guardian Signature (please print)<\/em><\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top has-display-below\">\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"parent-guardian-address\">Address of Parent or Guardian<\/label>\r\n\t\t\t\t<span><input name=\"parent-guardian-address\" id=\"parent-guardian-address\" required=\"\" class=\"form-control sig-width\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t\t<p class=\"display-below align-left\"><em>Address of Parent or Guardian<\/em><\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top has-display-below\">\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"home-work-phone-parent-guardian\">Home and Work Phones of Parent or Guardian<\/label>\r\n\t\t\t\t<span><input name=\"home-work-phone-parent-guardian\" id=\"home-work-phone-parent-guardian\" required=\"\" class=\"form-control sig-width\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t\t<p class=\"display-below align-left\"><em>Home and Work Phones of Parent or Guardian<\/em><\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n\r\n\t<div class=\"page-part mrgn-top inline-field has-display-below padd-botm\">\r\n\t\t<div class=\"form-group field field-text inline-field\">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"witness-signature\">Witness Signature<\/label>\r\n\t\t\t\t<span><input name=\"witness-signature\" id=\"witness-signature\" disabled=\"\" class=\"form-control sig-width\" value=\"\" type=\"text\"><\/span>\r\n\t\t\t\t<p class=\"display-below align-left\"><em>Witness Signature<\/em><\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t\t<div class=\"form-group field field-text inline-field \">\r\n\t\t\t<div class=\"input-cont\">\r\n\t\t\t\t<label class=\"control-label visuallyhidden\" for=\"witness-date\">Witness Date <span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n\t\t\t\t<span><input name=\"witness-date\" id=\"witness-date\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n\t\t\t\t<p class=\"display-below align-left\"><em>Date (dd\/mm\/yyyy)<\/em><\/p>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/div>\r\n<hr>\r\n\t\r\n\r\n\r\n   <button class=\"call-to-action print-form elementor-button col-full\" type=\"submit\">Print Form<\/button>\r\n\r\n\r\n  <\/form>\r\n\r\n<\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e40da87 text-link elementor-widget elementor-widget-button\" data-id=\"e40da87\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"\/wp-content\/uploads\/2022\/02\/FM.HIM_.001_Authorization_to_Release_PHI_-_English.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Download PDF<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3513770c elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3513770c\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-694effee\" data-id=\"694effee\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-78d1f6c1 elementor-widget elementor-widget-image\" data-id=\"78d1f6c1\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-widget-image{text-align:center}.elementor-widget-image a{display:inline-block}.elementor-widget-image a img[src$=\".svg\"]{width:48px}.elementor-widget-image img{vertical-align:middle;display:inline-block}<\/style>\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"100\" height=\"52\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\" class=\"attachment-large size-large wp-image-443\" alt=\"American College of Radiology\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-3d98581d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3d98581d\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-29f40293\" data-id=\"29f40293\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4a20d31f elementor-widget elementor-widget-heading\" data-id=\"4a20d31f\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Why Choose Us<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1adb96ae elementor-widget elementor-widget-text-editor\" data-id=\"1adb96ae\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p>SimonMed Imaging and its affiliates have been serving the community for over 30 years. Our mission is to provide best-in class affordable care through the use of advanced technology. We have patient-focused staff and highly trained medical professionals.<br \/><br \/>SimonMed has over 160 convenient locations across 11 states and provides late night and weekend appointments to accommodate patients.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-778fef6d img-choose-wrp elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"778fef6d\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-664ea56\" data-id=\"664ea56\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-682df634 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"682df634\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"86\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/radsite2.png\" class=\"attachment-medium size-medium wp-image-409\" alt=\"RadSite Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1b52ade elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"1b52ade\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"88\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-top-doctor.png\" class=\"attachment-medium size-medium wp-image-406\" alt=\"Top Doctor Icon\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7dc51a47 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"7dc51a47\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"78\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-interelated.png\" class=\"attachment-medium size-medium wp-image-407\" alt=\"Intelerad Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-db21c12 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"db21c12\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"81\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/02\/life_logo.png\" class=\"attachment-medium size-medium wp-image-755\" alt=\"LifeImage\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-658b52c1 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"658b52c1\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"81\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-sectra.png\" class=\"attachment-medium size-medium wp-image-408\" alt=\"Sectra Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-226ccc4e elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"226ccc4e\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"81\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-radsite.png\" class=\"attachment-medium size-medium wp-image-405\" alt=\"RadSite Icon\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Parental Consent Download PDF Parental Consent To Treat A Minor Form\u200b The following form is designed for those situations where minors are unaccompanied by either parents or legal guardians. This \u201cParental Consent to Treat A Minor Form\u201d gives authority to a designated adult to arrange for medical care for a minor. Medical care cannot be [&hellip;]<\/p>\n","protected":false},"author":10,"featured_media":0,"parent":46,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Parental Consent To Treat A Minor - SimonMed Website<\/title>\n<meta name=\"description\" content=\"Parental Consent Download PDF Parental Consent To Treat A Minor Form\u200b The following form is designed for those situations where minors are unaccompanied by either parents or legal guardians.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.simonmed.com\/patient-info\/parental-consent-to-treat-a-minor\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Parental Consent To Treat A Minor - 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