For an appointment, call (218) 454-7546 or (888) 841-2897
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For an appointment, call (218) 454-7546 or (888) 841-2897
Consent (Minor)

In the event I (or my child's other parent/legal guardian) am not able to accompany my child to their appointment. I hereby authorize

the above named persons to be able to accompany my child to their appointment. I hereby authorize them the right to consent to any examination, treatment, medical diagnosis, to be rendered to the minor under the general supervision and on the advice of any physician or surgeon licensed to practice in the state of Minnesota

I do hereby release, indemnify, and hold harmless all physicians and other persons who act in the reliance upon this authorization.

I permit a copy of this authorization to be used in place of the original

**The authorization will remain active until the minor child reaches the age of 18 or until the authorization is revoked.