Consent to Treat Minor Without Parent/Legal Guardian Present

If you would prefer to download a PDF version of this form and return it to the office, please click here.

  • To allow for treatment of patients who are considered minors, it is necessary for a parent or legal guardian to give consent for treatment. In the event that a minor child presents for a non-urgent appointment without a parent or legal guardian or a signed consent, treatment may be denied.

  • Date Format: MM slash DD slash YYYY
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PHONE 800.325.7706

Bloomington/Normal: (309) 829-5311
Bloomington/Retina: (309) 829-5311
Champaign: (217) 398-1700
Danville: (217) 446-3937
Decatur: (217) 875-0300
Forsyth: (217) 872-7404
Galesburg: (309) 343-6000

Gibson City: (800) 325-7706
Ottawa: (815) 434-4200
Pekin: (309) 347-5115
Peoria: (309) 692-8460
Peru / Lasalle: (815) 224-1100
Springfield: (217) 529-3937