Dual-signature assent form capturing a child's voluntary agreement to participate in a medical procedure or treatment, alongside parent/guardian consent. Designed for children ages 7–17; the minor signs in age-appropriate language and the parent co-signs.
The Pediatric Patient Assent Form is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 2 signers (parent and minor) and, by default, expires 30 days after it is sent if left unsigned. It covers dual signer, consent, healthcare, pediatric, minor assent, parent guardian. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Pediatric Patient Assent Form > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Healthcare Organization:** ___________ **Provider / Clinician Name:** ___________ **Child's Name:** ___________ **Child's Date of Birth:** ___________ **Child's Age:** ___________ **Parent / Legal Guardian Name:** ___________ **Relationship to Child:** ___________ --- ## About This Form This form has two parts. The first part is written in simple language for **___________** to read. The second part is for the parent or guardian. We believe that children old enough to understand should have a say in what happens to them. Signing this form means you agree to take part. You can always change your mind. --- ## Part 1 — For the Child (Ages 7 – 17) ### What We Would Like to Do Your doctor or care team wants to: **Procedure / Treatment:** ___________ **Why:** ___________