Can adolescents consent to their own medical care?

It depends on the state and the type of care. All 50 states permit minors to consent for certain categories without parental involvement: most commonly sexual and reproductive health (contraception, STI testing), mental health treatment, and substance use treatment. Some states extend this to all medical care for "mature minors" or emancipated minors. Age cutoffs vary widely — some states permit consent at age 12, others 14, others 16. HIPAA defers to state law on adolescent confidentiality. Practices should know the law in their state and have a policy for handling parent-vs-adolescent requests for records access.

What is HIPAA's rule on parent access to child records?

Under 45 CFR § 164.502(g)(3), the parent or guardian is generally treated as the personal representative of the unemancipated minor child and has access to the child's records. There are three exceptions: (1) the minor consents to the care alone where state law permits (e.g., adolescent reproductive health), (2) the minor lawfully obtains the care without parental consent and a court or other authorized person has consent for treatment, (3) the parent agrees to a confidential relationship between the minor and provider. The practice should also evaluate state-law privacy protections that may be more stringent than HIPAA.

Are vaccinations required to enroll in our practice?

Most pediatric practices have policies regarding vaccine-hesitant or vaccine-refusing families. The American Academy of Pediatrics permits practices to set their own policy — some accept vaccine-refusing families and continue to recommend vaccines at every visit; others require vaccines per CDC schedule with limited exemptions. State school-entry requirements often include vaccines (with religious or personal exemptions varying by state). The practice should articulate its policy clearly in the intake materials and discuss with families at the first visit.

Why ask about firearms in the home?

The American Academy of Pediatrics, the American Medical Association, and most pediatric authorities recommend routine firearm-safety counseling as part of well-child visits. Unintentional firearm injuries are a leading cause of pediatric death. Asking about presence and storage (locked, unloaded, ammunition stored separately) allows targeted anticipatory guidance. Some states have laws (e.g., Florida's former "Docs vs. Glocks" law, struck down by the 11th Circuit in Wollschlaeger v. Governor of Florida, 2017) attempting to restrict physician questions on firearms — these have generally been held unconstitutional. Counsel families on the safest practice (firearms not in homes with children).

Pediatric Patient Intake Form

New-patient intake form for pediatric clinics — child demographics, parent/guardian info, birth history, immunizations, school/daycare, HIPAA acknowledgement.

Customise

Practice / clinic name

Practice address

Practice phone

Child — full legal name

Child — preferred name / nickname

Child — date of birth

Child — sex assigned at birth

Child — gender identity (if different)

Child — home address

Child — race / ethnicity (optional, for population health)

Primary language spoken at home

Parent / guardian 1 — full name

Parent / guardian 1 — relationship

Parent / guardian 1 — phone

Parent / guardian 1 — email

Parent / guardian 1 — employer (for insurance)

Parent / guardian 2 — full name

Parent / guardian 2 — relationship

Parent / guardian 2 — phone

Custody arrangement (if separated/divorced)

Authorized to pick up child or receive medical info

Emergency contact (other than parents)

Insurance — company, policy holder, ID, group

Birth history

Developmental milestones

Current medications (name, dose, frequency)

Allergies (drugs, foods, environmental)

Past medical / surgical history

Family medical history (first-degree relatives)

Immunization status

Immunization notes / declinations

Current school / daycare

IEP, 504 plan, early intervention, or special services

Mental health, behavior, sleep, eating concerns

Safety screening (firearms, smoking, swimming, car seats)

Consent to treat (parental)

Consent date

Live preview

PEDIATRIC PATIENT INTAKE FORM

Practice:           Rose City Pediatrics
                    1234 NE Broadway, Portland, OR 97232
                    +1 503 555 0277

═══════════════════════════════════════════════════════════════════════
1. CHILD INFORMATION
═══════════════════════════════════════════════════════════════════════

Legal name:         Emma Sofia Taylor-Garcia
Preferred name:     Emmy
Date of birth:      September 22, 2018
Sex at birth:       Female
Gender identity:    Same as sex assigned at birth.
Home address:       482 Elm Street, Apt 3B, Portland, OR 97214
Race / ethnicity:   Hispanic / Latino, mixed (white + Mexican-American)  (optional)
Primary language:   English (Spanish secondary)

═══════════════════════════════════════════════════════════════════════
2. PARENTS / GUARDIANS
═══════════════════════════════════════════════════════════════════════

Parent/Guardian 1
  Name:             Jordan Alex Taylor
  Relationship:     Mother (legal & biological)
  Phone:            +1 503 555 0118
  Email:            jordan.taylor@example.com
  Employer:         Pacific Northwest School District #1

Parent/Guardian 2
  Name:             Miguel Angel Garcia
  Relationship:     Father (legal & biological)
  Phone:            +1 503 555 0119

CUSTODY ARRANGEMENT (if applicable)
Parents are married and reside together. No custody arrangement applies. (If separated: provide copy of custody decree to clinic.)

AUTHORIZED TO PICK UP / RECEIVE MEDICAL INFO
In addition to parents:
• Maria Elena Garcia (paternal grandmother) — +1 503 555 0233.
• Karen Schmidt (long-term babysitter) — +1 503 555 0301.
No one else without written authorization on file.

EMERGENCY CONTACT (other than parents)
Maria Elena Garcia (grandmother) — +1 503 555 0233

═══════════════════════════════════════════════════════════════════════
3. INSURANCE
═══════════════════════════════════════════════════════════════════════

Regence BlueCross BlueShield of Oregon
Policy holder: Jordan Alex Taylor (mother)
Member ID: 88312-Q-EMR
Group: GRP-OR-44218
(Card copy taken at first visit.)

═══════════════════════════════════════════════════════════════════════
4. BIRTH HISTORY
═══════════════════════════════════════════════════════════════════════

Pregnancy: planned, full-term (39w 4d). Mother's pregnancy uncomplicated. Prenatal care started at 8 weeks.
Delivery: vaginal, Providence Portland Medical Center; no instruments. Apgar 8/9. Birth weight 7 lb 4 oz (3.29 kg). No NICU. Discharged at 48 hours.
Newborn screen: normal. Hearing screen: passed bilaterally.

═══════════════════════════════════════════════════════════════════════
5. DEVELOPMENTAL HISTORY
═══════════════════════════════════════════════════════════════════════

All milestones met at expected ages:
• Smiled at 6 weeks. Sat unsupported at 6 months.
• Walked at 12 months. First words at 11 months.
• 50+ words at 18 months. Toilet-trained at 30 months.
• Currently reading simple books, can write own name, counts to 50.
No developmental concerns identified by parents or teachers.

═══════════════════════════════════════════════════════════════════════
6. MEDICATIONS, ALLERGIES, MEDICAL HISTORY
═══════════════════════════════════════════════════════════════════════

CURRENT MEDICATIONS
Children's multivitamin gummy daily (over-the-counter).
Albuterol HFA 90 mcg — 2 puffs as needed for wheeze (used about 2x/year).
No other medications.

ALLERGIES
Amoxicillin — diffuse rash at age 3 (no anaphylaxis). Avoid penicillin family.
Tree nuts — hives + lip swelling at age 4. EpiPen prescribed and carried at school.
No known environmental allergies.
No latex allergy.

PAST MEDICAL / SURGICAL HISTORY
Mild intermittent asthma — diagnosed age 4. Well controlled. No hospitalizations or emergency visits in past 12 months.
Ear tubes (myringotomy with tympanostomy tubes) age 2 — for recurrent otitis media. Tubes have extruded.
No other surgical history. No chronic illnesses.

FAMILY HISTORY
Mother (39): asthma (mild); migraine.
Father (41): seasonal allergies; no chronic illness.
Paternal grandfather: type 2 diabetes (diagnosed age 60).
Maternal grandmother: hypertension.
No family history of: childhood cancer, sudden cardiac death, hereditary syndromes, or genetic disorders known to family.

═══════════════════════════════════════════════════════════════════════
7. IMMUNIZATIONS
═══════════════════════════════════════════════════════════════════════

Status:             Up-to-date per CDC schedule — records will be uploaded

NOTES / DECLINATIONS
Records on file at previous PCP (Riverside Family Practice). Will request transfer.
Received: HepB, RV, DTaP, Hib, PCV13, IPV, MMR, Varicella, HepA, Influenza annually.
Not yet age-appropriate: Tdap, HPV, MenACWY, MenB.
No declinations.

═══════════════════════════════════════════════════════════════════════
8. SCHOOL / DAYCARE / SPECIAL SERVICES
═══════════════════════════════════════════════════════════════════════

Current school / daycare:
Sunnyside Elementary, kindergarten — Mrs. Park's class

IEP, 504 plan, early intervention:
None. School performance reportedly age-appropriate. No speech or occupational therapy. No behavioral concerns.

═══════════════════════════════════════════════════════════════════════
9. MENTAL HEALTH, BEHAVIOR, SLEEP
═══════════════════════════════════════════════════════════════════════

Generally happy and well-adjusted child. Sleeps 10-11 hours/night, predictable bedtime routine. Eats a varied diet (mild picky-eater stage normal for age). No major behavior concerns. No history of trauma. No exposure to domestic violence or substance use in home.

═══════════════════════════════════════════════════════════════════════
10. SAFETY SCREENING
═══════════════════════════════════════════════════════════════════════

Smoke-free home. No firearms in home or in homes child visits regularly.
Car seat: forward-facing 5-point harness, age- and weight-appropriate.
Swimming: completed beginner lessons; supervised at all times near water.
Working smoke and carbon monoxide detectors on every level of home.
Poison Control number (1-800-222-1222) saved in parent phones.

═══════════════════════════════════════════════════════════════════════
11. CONSENT TO TREAT AND HIPAA ACKNOWLEDGEMENT
═══════════════════════════════════════════════════════════════════════

CONSENT TO TREAT
I authorize the providers and staff of this practice to administer medical care to the child named above, including routine examinations, immunizations consistent with CDC recommendations (unless declined in writing), and emergency care as deemed medically necessary. I understand I have the right to be consulted on non-emergency treatment decisions.

HIPAA NOTICE OF PRIVACY PRACTICES
I acknowledge receipt of the practice's Notice of Privacy Practices
(HIPAA, 45 CFR § 164.520). I understand my child's protected health
information may be used and disclosed for treatment, payment, and
healthcare operations as described in the Notice. I understand that
I, as parent/guardian, have access to my child's records subject to
state-law exceptions (e.g., adolescent confidentiality protections
for reproductive, mental health, or substance use treatment under
applicable state law).

═══════════════════════════════════════════════════════════════════════
12. SIGNATURES
═══════════════════════════════════════════════════════════════════════


_____________________________________     May 11, 2026
Parent / guardian signature                Date

Printed name:       Jordan Alex Taylor

(If both parents have legal custody, both should sign when feasible.)


_____________________________________     May 11, 2026
Second parent / guardian signature         Date


_____________________________________     May 11, 2026
Reviewed by clinic staff                   Date

═══════════════════════════════════════════════════════════════════════
COPY TO PARENT — ORIGINAL TO CHART
═══════════════════════════════════════════════════════════════════════

About this template

A pediatric patient intake form differs from an adult intake form in several substantive ways. First, demographic information must capture both the child and the legally responsible parents or guardians. Second, custody arrangements have direct legal consequences for who can authorize treatment and access records — divorced or separated parents may have differing decision-making authority, and step-parents typically have NO legal authority absent court order or written designation. Third, the medical history must capture the prenatal period, birth, and developmental trajectory — this is uniquely pediatric and uniquely important. Fourth, immunizations are central to pediatric care; the form should capture status against the CDC Recommended Immunization Schedule (which is updated annually by the Advisory Committee on Immunization Practices and published at cdc.gov/vaccines/schedules). Fifth, school and daycare information matters for several reasons: communicable-disease exposure, immunization records for school-entry compliance, IEP/504 plans for chronic conditions, and behavioral health context. Sixth, safety screening is age-specific (car seats, sleep position for infants, water safety, firearms, smoking exposure, ingestion poisoning) and the American Academy of Pediatrics Bright Futures guidelines (brightfutures.aap.org) provide age-specific anticipatory guidance. Seventh, mental and behavioral health screening must be developmentally appropriate; common screening tools include the M-CHAT-R/F (autism screening at 18 and 24 months), Ages and Stages Questionnaire (ASQ), and PHQ-9 modified for adolescents. Eighth, the consent-to-treat must come from a parent or guardian with legal authority. Mature-minor and emancipated-minor doctrines vary by state — most states permit minors to consent to specific categories of care (sexual health, mental health, substance use treatment) without parental involvement; some states have age-of-majority cutoffs as young as 12 for these categories. Ninth, HIPAA recognizes the parent as the personal representative of the minor child for most purposes (45 CFR § 164.502(g)(3)) but with state-law exceptions for the categories above. Tenth, the form should capture authorized pickup persons and emergency contacts beyond the parents — divorced parents, grandparents, babysitters, and neighbors often need to be designated. The mandated-reporter framework should be implicit in any pediatric care: physicians, nurses, and clinic staff are mandatory reporters of suspected child abuse and neglect under state law and the Child Abuse Prevention and Treatment Act (CAPTA, 42 USC § 5101 et seq.); the intake form is not the place to formally document this but the practice should have policies. Pediatric data privacy under COPPA (Children's Online Privacy Protection Act, 15 USC § 6501) applies to web-based intake forms collecting information from children under 13. Practice considerations: (a) translation services should be available for non-English-speaking families (Title VI of the Civil Rights Act, 42 USC § 2000d, requires meaningful access for limited-English-proficiency individuals at federally funded providers); (b) gender-affirming care policies and inclusive language should match the practice's patient population; (c) immigration status should NOT be collected — it has no clinical relevance and creates legal risk. This template targets a routine well-child new-patient intake in primary care; specialty intake (pediatric oncology, pediatric cardiology, behavioral health) typically supplements this with specialty-specific questions.

When to use it

New-patient appointment for an infant, child, or adolescent.
Transferring care from another pediatrician or family medicine provider.
Establishing care after a move, change of insurance, or change in custody.
Annual update of intake information for an established patient.
School-entry physicals (immunization compliance often documented separately).

What to include

Child legal name, preferred name, DOB, sex at birth, gender identity.
Parent / guardian information with relationship and contact.
Custody arrangement and decision-making authority.
Authorized pickup persons and emergency contacts.
Insurance information.
Birth history (pregnancy, delivery, newborn period).
Developmental milestones.
Current medications, allergies, past medical/surgical history.
Family history (first-degree relatives at minimum).
Immunization status against CDC schedule.
School/daycare/special services (IEP, 504, early intervention).
Mental, behavioral, sleep, and eating screening.
Age-appropriate safety screening (car seat, firearms, water, smoke detectors).
Consent to treat and HIPAA acknowledgement.
Signature of parent/guardian with legal authority.

Frequently asked

A parent or legal guardian with decision-making authority. In intact families, either parent typically has authority to consent to non-emergency medical care. In separated/divorced families, the custody decree governs — joint legal custody usually means either parent can consent; sole legal custody means only the designated parent can consent for non-emergency care. Step-parents have NO legal authority absent court order or formal designation. Grandparents, aunts/uncles, or other relatives need a written authorization (some states use a "Caregiver's Authorization Affidavit" form) or formal guardianship. In emergencies, the doctrine of implied consent permits treatment regardless.

⚠ Legal disclaimer. This intake form is designed for general pediatric primary care. Custody and consent rules are governed by state family law (each state's family code) and the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA, adopted in all 50 states except Massachusetts). Adolescent confidentiality rules vary widely by state — consult your state Department of Health, the Guttmacher Institute (guttmacher.org/state-policy/explore/overview-minors-consent-law), and AAP guidance. HIPAA personal-representative rules for minors at 45 CFR § 164.502(g)(3). Title VI of the Civil Rights Act (42 USC § 2000d) requires meaningful access for limited-English-proficiency families. Mandatory reporting of suspected child abuse is required under state law and CAPTA (42 USC § 5101 et seq.). CDC immunization schedule at cdc.gov/vaccines/schedules. AAP Bright Futures guidelines at brightfutures.aap.org. Not legal or medical advice — consult counsel and your state department of health.

Jurisdiction: United States — federal HIPAA Privacy Rule (45 CFR Parts 160, 164); 42 CFR Part 2 SUD records (89 Fed. Reg. 12472 final rule, eff. 04/16/2024); state medical-practice statutes; ADA Title III (42 U.S.C. §§12181-12189) + state public-accommodations law.

Last reviewed: 2026-05

Reviewed by ScoutMyTool — consult a licensed attorney for binding use.