We understand that work life circumstances may occasionally prevent a parent/legal guardian from coming to an appointment with a child who is under the age of eighteen. We work hard to balance patient needs and our medical responsibility to ensure the optimal and collaborative health care of our patients who are becoming young women.

Initial Visit
Please complete the new patient form as well as the “Authorization for Gynecological Exam of a Minor.” Patients under the age of eighteen, must be accompanied by a parent or legal guardian for their visits. Exceptions to this rule are emancipated minors. The classifications of emancipated minors who may consent to medical services for themselves are a person who has graduated from high school, a married person, a person who has been pregnant, and a person who presents for diagnosis or treatment of pregnancy or venereal disease.

An authorization from the minor is normally required for any disclosure to the minor’s parent(s)/guardian of venereal and reportable diseases, pregnancy testing and care. HIV related information is protected.

Minor patients are required to list someone to whom we can release medical information.

We recommended that the parent/guardian accompany the patient to the exam room to help with review of family history. The patient may request that her parent/guardian step out into the hall or waiting room during the exam.

****Failure to have a parent/legal guardian accompany the patient to her initial appointment will result in the minor not being seen and the appointment being rescheduled to the next available New Patient appointment***

Subsequent Visit
If a parent/guardian is unable to accompany the minor, then another authorized and responsible adult must accompany them.

The “Medical Consent Authorization (Non-Parent Consent) Form” must be completely filled out and returned to the office PRIOR to the subsequent visit. The authorization form can be picked up at the front desk, mailed upon request or obtained at the end of the initial visit.

***Failure to complete and return the required “Medical Consent Authorization (Non-Parent Consent) Form will result in rescheduling the appointment. ***

Authorization For Gynecological Exam of Minor

I hereby authorize the Providers at Altoona OB-GYN Associates, Inc. to perform a Gynecological exam on stated minor
Check one(Required)
I understand that this consent authorizes the Provider to order all tests deemed appropriate for the patient at this visit. These tests may include, but are not limited to, pap smear, screening tests for sexually transmitted diseases and other labs. I further understand that the Provider may discuss issues such as sexual activity, methods of birth control and sexually transmitted diseases. I agree that the Provider may perform treatments (including vaccines) and or give prescriptions as indicated.

I understand that I am responsible for any financial obligation incurred at this visit or follow-up visits.
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