Form 130D University of Texas Arlington Health Services Box 19329

University of Texas Arlington Health Services
Box 19329 605 S. West St. Arlington, TX 76019 T. 817.272.2771 F. 817.272.3829
www.uta.edu/healthservices
Patient Name: ______________________________________
UT Arlington I.D. #: ________________________________
D.O.B.: _________________
Gender: ______________
Provider: _____________ Date: ________________
CONSENT FOR TREATMENT OF
A MINOR WHO DOES NOT
HAVE LEGAL POWER TO
CONSENT
Information and Consent
Name of Minor: _______________________________________________________________________
Date of Birth: ____________________________________
Address (Street, City, State, Zip Code): ____________________________________________________
____________________________________________________________________________________
Parent/Guardian Phone Number: ____________________
_________________________
HOME
WORK
I, the undersigned as the parent or legal guardian of _________________________________________ (a
minor) hereby authorize such diagnostic, medical and/or surgical treatment of such minor as may be
considered necessary or appropriate under the circumstances for the treatment of any illness or injury of
the minor. The attending physician, appropriate staff, and The University of Texas at Arlington and its
officers, regents, and employees shall not be responsible in any way for any consequences from said
diagnostic, medical, and/or surgical treatment and are hereby released from any and all claims and causes
of action that may arise out of, or be incident to such diagnosis, treatment, or surgery insofar as the law
allows and provided that these services are performed with ordinary care and to the best of their ability.
___________________________________________________________
___________________
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE
_________________________________________________________________________________
PRINT NAME
Medical Information Related to Minor:
Allergies: ____________________________________________________________________________________________
Current Medications: __________________________________________________________________________________
Date of Last Tetanus Booster: ___________________________________________________________________________
Pertinent Medical History: ______________________________________________________________________________
â–¡ CONDITION WAS URGENT.
Parental/guardian consent for treatment was obtained by telephone from:
_______________________________________________________________________ ________________________
NAME OF PARENT/LEGAL GUARDIAN
TIME AND DATE
By ____________________________________________________________________________
Form 130D