Consent for Treatment of a Minor In accordance with Michigan law, University Health Services at EMU requires parental consent before treating minors in the clinic (except in the case of emergencies and other exceptions under law). PLEASE COMPLETE THIS FORM IF YOUR STUDENT IS UNDER THE AGE OF 18. If a minor requests care and no consent is on file, UHS will attempt to contact the parent/guardian, but may lead to a delay in care. ______________________________________________________________________ Minor Name __________________________________ ________________________________ Date of Birth E# If medical treatment is required, I hereby give my consent and authorize University Health Services at Eastern Michigan University or the closest hospital emergency department to provide medical/psychological diagnostic and treatment services. ______________________________________________________________________ Parent/Guardian Name _____________________________________________ Relationship to minor ( ____ ) _____­_________ Daytime phone ______________________________________________________________________ Address City State Zip _____________________________________________ ______________________ Signature Date RETURN BY FAX OR MAIL TO: MEDICAL RECORDS EASTERN MICHIGAN UNIVERSITY MAIN FLOOR, SNOW HEALTH CENTER YPSILANTI, MI 48197 PHONE: 734.487.1122 FAX: 734.487.2342