Consent for Treatment of a Minor by Parent/Legal Guardian

I, the undersigned, as parent or legal guardian of:
Name: Name: First Last
Date of Birth: Date of Birth: / MM / DD YYYY
Panther ID:
confirm I:

confirm I: have the legal authority to give consent for the treatment of this minor. I hereby authorize Florida International University Student Health Clinics, to provide such diagnostic or medical treatment to such minor as may be considered necessary or appropriate under the circumstances which may include, without limitation, arranging for and/or authorizing consultation, evaluation, referral, treatment, including medication and/or vaccine administration, for the above named minor. I agree that treatment may be provided in my absence. This consent shall remain in effect unless it is revoked in writing.
Draw your signature into the box below. A TYPED SIGNATURE WILL NOT BE ACCEPTED.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Parent/Guardian Name: Parent/Guardian Name: First Last
Relationship to Minor:

Relationship to Minor: Parent Legal Guardian Other (please specify) Other (please specify)
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Please upload a copy of the parent/guardian valid ID or driver’s license to this consent form.

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