This form provides parent consent for the adolescent questionnaire that is discussed at well visits for ages 17 years and younger.

This form is completed with parent consent at adolescent well visits for ages 17 years of age and younger.

This form is completed at well visits for ages 18 years of age and older.

Updated April 2025

Please Note: Portions of this form need to be completed by the parent and student before it can be provided to your pediatrician. Click here to learn more.