Minor/Parent/Guardian Consent & Custody Information

Click the fields below to fill them out.

Complete when the patient is a minor. The practice may request legal documentation needed to confirm authority to consent to treatment.

Online submission is not available yet. Please download the PDF version, call (240) 753-7276, or fax (240) 753-7279, and our team will help you complete this form.

Patient details

Patient full legal name *

Date of birth *

Email address *

Callback number *

State or district *

Parent, guardian, and custody information

Parent or legal guardian name *

Relationship to patient *

Custody, consent authority, and relevant restrictions *

Electronic acknowledgment

Electronic signature consent *

I agree to use an electronic signature and intend my typed name to serve as my signature.

Type your full name to sign *

Date signed *

I consent to electronic submission and understand this form is not monitored for emergencies. I have reviewed the website Privacy Policy.