1317 W. Diversey Parkway
Chicago, Illinois 60614 (map)
PH: (773) 665-9355
FAX: (773) 665-0403
Chicago Family Practice Since 1994

Parental Consent for Medical Treatment of Minor

When parents cannot be present at the time of their child’s appointment, it is the policy of Lincoln Park Family Physicians, S. C. that no child under the age of thirteen will be treated in the office without a designated adult chaperone present.

Children between the ages of thirteen and eighteen who will be coming to the office alone must either have a signed or verbal consent form on file prior to being treated.

In order to save you time during your visit with Lincoln Park Family Physicians, please print out and complete the below form.

Parental Consent Form

Patient Responsibilites & Policies

View more information about patient responsibilites and polices here.

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