Consent for Medical Treatment of a Minor

The safety of our employees and their family, our patients, are paramount above all else. As we learn more about the novel coronavirus and the disease it cases (COVID-19), we all have to do our part to limit its spread. We reply on guidance from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and local health officials to guide our health and safety precautions as we continue to operate as an essential business that’s part of the nation’s critical infrastructure.

To that aim, Water & Sports Physical Therapy has implemented enhanced screening of all employees and patients who come to a WSPT clinic. Your honest participation in this process is critical to maintaining everyone’s well being during this time.

Please answer the questions listed before coming in for your appointment.

I, the undersigned legal guardian, hereby (grant/do not grant) providers at Water & Sports Physical Therapy, Inc. the authority to obtain medical treatment for the following child(ren):
Name of Child(ren)*
Birthdate(s):*
The above care provider(s) shall have the authorization to:
- - Obtain medical treatment and procedures for the child(ren) as may be appropriate in emergency circumstances, including treatment by physical therapists, physicians, hospital and clinic personnel, and other appropriate health care providers.
- - Obtain routine medical treatment from appropriate health care providers if symptoms of illness occur (e.g., fever, coughing, irregular breathing, unusual rashes, swallowing problems, etc.).
PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE.
Date*
MM slash DD slash YYYY
Option 1.
- Yes
I allow my child to be treated by the licensed physical therapist when I am not present. I understand that my child is a minor and allow him/her to be treated by the licensed physical therapist when I am not present. I fully understand the risks that are involved with a physical therapy evaluation and treatment programs.
Option 2.
- No
I do not allow my child to be treated by the licensed physical therapist when I am not present. I understand that my child is a minor and do not allow him/her to be treated by the licensed physical therapist when I am not present. I would like to be present when there is any treatment being performed.
Date*
MM slash DD slash YYYY

This grant of temporary authority shall begin on the date selected and shall remain effective until terminated by the undersigned.
In case of an emergency, the care provider(s) should first try to contact the parent(s). If the parent(s) cannot be reached, the care provider should then contact the following person(s) listed below:
Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Patient's Name*
First Last
Patient Signature (or Guardian)*
Date*
MM slash DD slash YYYY
Which location are you going to?*

Consent for Medical Treatment of a Minor

CARMEL VALLEY

CARMEL VALLEY (POOL)

CORONADO

CORONADO (POOL)

MISSION BEACH

MISSION BEACH (POOL)

DOWNTOWN

DOWNTOWN (POOL)

SCRIPPS RANCH

Scripps Ranch Pool

POWAY

LA JOLLA

UTC

SDCST