{"content":[{"text":"Consent to Treat Minor Patient-Without Parent/Legal Guardian Present \n By law, any child under the age of 18 years old cannot be seen by a doctor without consent from a parent or legal \n guardian. If the minor arrives with someone other than a parent or legal guardian, or arrives unaccompanied, we must \n have written permission from the parent or legal guardian that the person accompanying the minor has been appointed \n by you to act on your behalf, or that the minor can act on their own behalf.","bbox":{"left":0.082353,"top":0.105306,"width":0.835609,"height":0.10287900000000001}},{"text":"Minor’s Name: ________________________________ Date of Birth: ___________________","bbox":{"left":0.082353,"top":0.223664,"width":0.68181,"height":0.015437000000000006}},{"text":"For those occasions when you may not be with your child, please list those individuals who may give us consent to \n see your child: \n Name: ___________________________ Phone: __________________ Relation to Patient: _________________ \n Name: ___________________________ Phone: __________________ Relation to Patient: _________________ \n Name: ___________________________ Phone: __________________ Relation to Patient: _________________ \n Name: ___________________________ Phone: __________________ Relation to Patient: _________________ \n Name: ___________________________ Phone: __________________ Relation to Patient: _________________ \n Name: ___________________________ Phone: __________________ Relation to Patient: _________________","bbox":{"left":0.082353,"top":0.253377,"width":0.834877,"height":0.17590599999999995}},{"text":"LIMITATIONS: Identify any specific limitations on the kinds of services for which this authorization is given. (If \n none, state “none”). \n _____________________________________________________________________________________","bbox":{"left":0.082353,"top":0.450233,"width":0.835055,"height":0.05056499999999997}},{"text":"AUTHORIZATION: I (parent/legal guardian name) _________________________________ request and authorize \n Family Health Services of Darke County, Inc. and its personnel to deliver routine medical care to the minor person \n listed above as may be deemed necessary or advisable in the diagnosis and treatment of the minor person. I am also \n aware that the adult presenting the minor, or the minor is responsible for payment of the patient portion at the time \n of service. I have the legal right to preauthorize Family Health Services of Darke County, Inc. and its personnel to \n deliver routine medical treatment and services to the minor. Routine medical care and interventions may include, but \n are not limited to: medical evaluation, physical exam, immunizations, injections, x-rays, lab work (examples: throat \n or nasal swabs, blood draws, wart treatment with liquid nitrogen, minor burns, minor suturing of lacerations). I have \n read, understand, and give my consent as stipulated above. My signature means that I have read this form and/or have \n had it read to me and explained in the language that I can understand.","bbox":{"left":0.082353,"top":0.514021,"width":0.8355910000000001,"height":0.1624080000000001}},{"text":"This consent shall be in effect for","bbox":{"left":0.082353,"top":0.689804,"width":0.24057099999999998,"height":0.018595000000000028}},{"text":"Date: _________ (Only)","bbox":{"left":0.367878,"top":0.689804,"width":0.176796,"height":0.018595000000000028}},{"text":"Indefinitely, until revoked by written notice.","bbox":{"left":0.594138,"top":0.689804,"width":0.31886099999999995,"height":0.018595000000000028}},{"text":"_____________________________________________________________________________________ \n Parent or Legal Guardian (please print) Phone Number Relationship","bbox":{"left":0.082353,"top":0.721774,"width":0.768398,"height":0.03450399999999998}},{"text":"_____________________________________________________________________________________ \n Parent/Guardian Signature Date","bbox":{"left":0.082353,"top":0.76969,"width":0.763888,"height":0.03450500000000001}},{"text":"Return to Family Health in-person or send to: \n Fax: 937.548.2087 \n Email: medicalrecords@familyhealthservices.org","bbox":{"left":0.082353,"top":0.867182,"width":0.38831399999999994,"height":0.05462100000000003}}],"images_bbox":[{"left":0.082353,"top":0.017121,"width":0.166471,"height":0.072879}],"images_bbox_not_text_overlap":[{"left":0.082353,"top":0.017121,"width":0.166471,"height":0.072879}]}