Consent form - minors

• Children up to 12 years: not mentally competent; parents or guardian must give permission for treatment and sign this form with the practitioner.

• Minors aged 12 to 16: potentially mentally competent; In principle, the consent of both the minor and the parents/guardian is required for treatment, which must be signed together with the practitioner.

• Minor aged 16 to 18: in principle mentally competent; This form does not need to be signed for treatment unless the minor is not mentally competent.

 

If there is not one but two parent/guardian authority, this form must be signed by both parent/guardian authority and the practitioner. (The first parent/guardian with authority is responsible for any lack of consent in case there is another authority holder.)

 

Date:  _____________________                                        Place:     ______________________                                     

 

Signature parent (1) or guardian:   _____________________________

 

Signature parent (2):     _________________________

 

Signature minor: 12 to 18 years

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__________________________________

 

Practitioner signature:

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__________________________________

 

Dates of release appointments:

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1st appointment:        ____________________                                  

2nd appointment:      ____________________                                 

3rd appointment:       ____________________

Follow-up appointments:   ________________