Minor Child Medical Consent Form

CONSENT BY MINOR TO MEDICAL, DENTAL,

PSYCHOLOGICAL, OR SURGICAL CARE

Under Chapter 33 of the Texas Family Code, an unemancipated minor cannot consent to an abortion.

Prepared by the Texas Foster Youth Justice Project Updated 11/06/2019

This consent form constitutes a written statement under Section 32.003(f) of the Texas Family Code. A

physician, dentist, psychologist, hospital, or medical facility may rely on the written statement of the

child containing the grounds on which the child has capacity to consent to the child's medical treatment.

The consent by a child to medical, dental, psychological, and surgical treatment is not subject to

disaffirmance because of the child’s minority. Tex. Fam. Code § 32.003(b).

I, [name of minor] ______________________________, am currently [number of years] ____ years of

age. My date of birth is ______________________________.

My father’s name (if known) is _______________________________. My mother’s name (if known) is

______________________________. IF APPLICABLE: The name of my managing conservator or

legal guardian is ______________________________.

I, [name of minor] ______________________________, give consent for my own medical treatment.

The nature of the medical treatment to be given to me is as follows:

 Medical:

 Dental:

 Psychological:

 Surgical:

The treatment is to begin on [start date for treatment]:

I have legal authority to consent to the treatment described above under Tex. Fam. Code § 32.003

because I (check one or more):

 am on active duty with the armed forces of the United States of America

 am 16 years of age or older and reside separate and apart from my parents, managing conservator,

or guardian, and manage my own financial affairs

 consent to the diagnosis and treatment of an infectious, contagious, or communicable disease as

required by law or rule to be reported by the licensed physician or dentist to a local health officer or

the Texas Department of State Health Services and including all diseases within the scope of Tex.

Health & Safety Code Ann.§ 81.041

 am unmarried and pregnant and consent to hospital, medical, or surgical treatment, other than

abortion, related to the pregnancy

 am consenting to examination and treatment for drug or chemical addiction, drug or chemical

dependency, or any other condition related to drug or chemical use

 am unmarried, am the parent of a child, have actual custody of my child, and consents to medical,

dental, psychological, or surgical treatment for the child

I certify that I have read and fully understand the above consent; that the facts indicated above are true;

and that all blanks or statements requiring insertion or completion were filled in before I signed.

Minor Name (Printed)

Minor Signature

Date of Consent

SAMPLE