Parental Concent Form

When a minor is receiving treatment, consent from a guardian is required.
Guardians, please download the consent form below, print it out, fill it in by hand, sign, and affix your seal.

• Please fill in the form by hand. Entries made using a computer or other electronic devices will be considered invalid.
• Please use a ballpoint pen or similar writing instrument, not a pencil.
• If there are any omissions or errors in the consent form, treatment cannot be provided.
• For the “Treatment Name” section, if the treatment has not been decided yet, please indicate your desired treatment.