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University of New Hampshire Health Services Form #205.1 Permission to Treat Underage Student/Patient For Patients/Students Age 17 and Under Please Print Student/Patients Name: Last First MI Date of
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How to fill out permission to treatagreement to
How to fill out permission to treat agreement:
01
Start by entering the date at the top of the form.
02
Fill in the patient's full name, address, and contact information.
03
Provide the name of the authorized caregiver or guardian who will be giving consent for treatment.
04
Specify the relationship between the caregiver or guardian and the patient.
05
Indicate the patient's date of birth and any relevant medical conditions or allergies.
06
Include emergency contact information, such as a phone number or address.
07
Sign the document to acknowledge that you give permission for the specified caregiver or guardian to make medical decisions for the patient.
08
If required, have the document notarized or witnessed by a third party.
09
Keep a copy of the permission to treat agreement for your records.
Who needs permission to treat agreement:
01
Parents or legal guardians of minors who are unable to provide consent for medical treatment.
02
Caregivers or family members who are responsible for the care of individuals with physical or mental disabilities.
03
Individuals who have been designated as healthcare agents with the authority to make medical decisions for someone who is incapacitated.
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