Authorization to Accompany and/or Consent to Limited Treatment

Read and add electronic signature below.

I. Fill out and sign this section TO AUTHORIZE INDIVIDUALS (18 and older) TO ACCOMPANY TO CLINIC VISITS.


*Please Note: Submitting this form will invalidate all prior authorizations to accompany and/or consent for treatment.*
(Patient's full name)
(Name of person accompanying patient)
(Name of person accompanying patient)
(Name of person accompanying patient)
(Name of person accompanying patient)
to accompany the above-named patient to his/her clinic visits. I understand that this delegation includes and authorizes receiving health information, including discharge instructions, related to services provided during clinic visits where the above-named individual accompanied patient.

This authorization to accompany remains in effect until terminated in writing by me; the patient regains legal capacity or reaches age of majority or my legal authority over the patient changes.

II. Fill out and sign this section TO AUTHORIZE ACCOMPANYING ADULTS TO CONSENT TO TREATMENT.


I, the undersigned parent OR legally authorized representative of the above-named patient do hereby authorize the above-named individuals (age 18 and above) to also act as the representative(s) for the above-named patient and to have the same full authority that I have to consent to, or withhold consent to, any primary and preventive medical care, immunizations, diagnostic testing and other medically necessary healthcare and treatment, which examination and treatment shall be prescribed by or under the supervision of a physician, podiatrist, optometrist, physician assistant, advanced practice nurse or mental health professional.
MM slash DD slash YYYY
(No more than 10 years from date of signature)
  • The patient regains legal capacity or reaches the age of majority.
  • The authorization to accompany and/or consent is terminated in writing by me and communicated to the healthcare provider in possession of this form; or
  • My legal authority over the patient changes, whichever happens first.

    • III. Complete and sign.

    I am filling this form out as the patient's
    I can be contacted at:
    Address