Non-Parent Consent Form - Mississippi Pediatric Endocrine Care

Temporary Consent

For someone other than parent or guardian to bring minor child to appointment.

I am the parent or legal guardian of the minor patient,

First Last

Minor Patient Name

First Last

Date

I have the legal right to consent for medical treatment for the patient.

As I am unable to be present during this appointment, I authorize the following responsible adult,

Name

First Last

Date

to bring the patient to their appointment and give consent for medical care. I understand such medical care may include treatments deemed medically necessary by the providers at Mississippi Pediatric Endocrine Care. I authorize this person to also receive confidential health information about the patient which may include test results, diagnosis, treatment plan, and follow-up instructions. I understand it is my responsibility to discuss the information given with this person and that I may contact MSPEC with any questions I may have. I understand it remains my responsibility to follow through with the treatment plan, patient instructions, and recommended follow-up despite the fact I was not present during the appointment.

Signature

Date

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Phone

This field is for validation purposes and should be left unchanged.

Temporary Consent

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