Advanced Consent to Treat Minor Children (under 18 years of age)

Originally effective: 12/1/2020

The providers and staff of Kaufman Allergy Asthma and Immunology, PLLC place great emphasis on the health and well-being of each and every patient in our clinic and we appreciate that you have entrusted us to provide health care services to your minor child. We look forward to working with you to ensure that your child receives the best health care possible.

We require the consent of a parent or legal guardian in order to provide health care services to a child under the age of 18 years. With so many parents working outside the home or with other commitments, we realize that you may not be able to accompany your child on every visit to the clinic.

We do require that a parent or legal guardian accompany a minor child to his or her first visit at our clinic. Additionally, all children under the age of 18 years must be accompanied by an adult to all visits where procedures are performed (i.e., allergy testing, allergen immunotherapy).

In the case that an adult who is not the patient’s parent or guardian (i.e. other relative, babysitter) accompanies the child to follow up or procedure visits, this consent form designates the name of the aforementioned adult and authorizes our practice to provide care to your child.

We also allow parents or legal guardians to provide advanced consent for the routine treatment of their children under the age of 18 years who arrive unaccompanied for routine follow up visits.

By providing consent, Kaufman Allergy Asthma and Immunology, PLLC will be allowed to provide routine care and emergency medical treatment if needed for your minor child when deemed necessary by our treatment team. This consent will remain in effect until revoked in writing.

By signing this advanced consent, I hereby acknowledge the following:

• Children under the age of 18 years are required to be accompanied by an adult to all procedure visits (i.e., allergy testing or allergen immunotherapy). If they arrive unaccompanied for a procedure visit, the appointment will need to reschedule, and a missed appointment fee will be incurred.
• I may authorize my child under the age of 18 years to be treated at a follow up visit in my absence if her or she arrives unaccompanied by a parent, guardian, or designated adult.
• I may authorize the adult(s) designated on this form to accompany my child under the age of 18 years to follow up or procedure visit(s), and that authorization may be revoked at any time in writing.

                                                                                                                                                                       
Patient’s name                                                                                               Date of Birth

                                                                                                                                                                       
Signature of Responsible Party (guarantor)                                           Relationship to Patient

                                                                                                                                                                       
Sign here if minor child may arrive for follow up visits unaccompanied.

                                                                                                                                                                       
Name of Designated Adult (other than parent or guardian)              Relationship to Patient
who may accompany your child to visits