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    Wittenberg University Consent to Treatment of a Minor

    Consent to Treatment of Minor (to be completed only if students is under the age of 18)

    Student who are minors cannot be treated for health related services without parental or guardian consent unless: 1) the minor student is authorized by law to consent for treatment; or 2) obtaining informed consent is impracticable and a serious threat to the minor student’s life or health exists that must be dealt with immediately.

    Student Information
    Parent, Custodian, or Guardian Information
    Consent

    In the event that there is a need for routine or emergency medical care that is the result of an injury and/or illness, I authorize and give consent for Wittenberg Health Center operated by CMHP and the Sports Medicine Department to administer all inpatient/emergency/outpatient medical care, encompassing routine diagnostic procedures and medical treatment by an attending physician, nurse practitioner, nurse, assistant, consultant or designee, and any necessary mental health or substance abuse counseling, to the above named student, as is necessary in their professional judgement, in accordance with state law, and refer the above named student to duly licensed medical facilities and/or practitioners when indicated. For surgical procedures, or more extensive medical care, attempts will be made to contact me before such care is initiated.

    In the event that there is a need for routine or emergency medical care that is the result of an injury and/or illness, I authorize and give consent for Wittenberg Health Center operated by CMHP and the Sports Medicine Department to administer all inpatient/emergency/outpatient medical care, encompassing routine diagnostic procedures and medical treatment by an attending physician, nurse practitioner, nurse, assistant, consultant or designee, and any necessary mental health or substance abuse counseling, to the above named student, as is necessary in their professional judgement, in accordance with state law, and refer the above named student to duly licensed medical facilities and/or practitioners when indicated. For surgical procedures, or more extensive medical care, attempts will be made to contact me before such care is initiated.

    I further understand that once my child reaches the age of majority, my consent for treatment is no longer required.

    I further understand that once my child reaches the age of majority, my consent for treatment is no longer required.

    NOTICE: I attest that the above information is correct to the best of my knowledge. I also understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered or fees associated with the care of the above named student.
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