Parent / Guardian Consent for a Minor to Receive Health Care Services

A parent or legal guardian must give consent in order for U-M students who are minors (under age 18) to receive health care services at University Health Service (UHS). 

A parent or legal guardian should complete this form. (You may use free Adobe Acrobat Reader to read the form.)

Form for Parents/Guardians to
Give Consent for a Minor to Receive
Health Care Services at UHS (PDF)

After completion, please mail the form to:
  University Health Service
  HIM-Forms
  207 Fletcher Street
  Ann Arbor MI 48109-1050

Or fax to 734-936-3063

This form is for use at University Health Service only. It does not pertain at Michigan Medicine hospitals or clinics.

Please do not upload this consent form when submitting immunization records.