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Permission to Treat Minor Form

We perform the Ohio Department of Job and Family Services Employee physical using this form*.

*PLEASE NOTE: All required vaccination records must be presented at the time of the visit in order to complete the physical.

Buehler’s clinics are now open
M thru F from 10 to 4. All ACME clinics temporarily closed.

Covid testing now available at Buehlers locations.
BY APPOINTMENT ONLY
Call for your appointment:
Wadsworth: 330.336.3588 Option 15, Option 0
Medina: 330.725.0535 Option 15, Option 0

Minor Injuries

Minor Illnesses

Age requirement is 2 years and above…

Family Statcare requires all patients 18 and under to be accompanied by an adult. If the parent/guardian cannot be present, this consent to treat form must be completed by parent/guardian with permission for another adult to bring child in. This form is required to be seen and must be presented at the time of service.