PatientPower — Parent/Guardian Consent (Minor)

Consent to use PatientPower — for a Minor

Completed by the parent or legal guardian, on behalf of a patient under 18

A parent or legal guardian must review and agree to the following before a minor's care plan can be viewed in PatientPower. Please confirm the details below.

About the patient (the minor)

Minor's full name *

Date of birth *

About you (parent / legal guardian)

Your full name *

Relationship to the minor *

By continuing, I confirm that I am the parent or legal guardian of the minor named above and I have the legal authority to consent to the use of this app on their behalf.

I acknowledge and agree, on behalf of my child, that:

My child's care plan is created and managed by their provider; this app supports that plan and does not replace professional care.
I authorize the office to send secure electronic communications (notification emails that contain no health details — I sign in to view the plan).
This app is for non-emergency use only; for emergencies I will call 911.
I may stop using the app and request deletion of my child's information at any time.
I understand I am consenting on behalf of a minor, and that my access to their information may change as required by law — for example, when the minor reaches the age of majority, or for certain confidential adolescent services that the law lets the minor control.

Minor's assent (optional, recommended for ages 12+)

Minor's name confirming they agree to participate (optional)

I have read and agree to all of the above, and I confirm I am the minor's parent or legal guardian with authority to consent on their behalf.

Signature (type your full name) *

Date *

This is a template consent form for PatientPower (beta). It should be reviewed by your legal/compliance advisor before use with real patients, and requirements for minor consent vary by state. Health details are never included in any email or text — only a secure sign-in link.