Abortion Parental Consent Form – For a Minor (Child)

Updated June 03, 2022

A parental consent form for a minor’s abortion is required in select States as a means for an unemancipated minor to receive a legal abortion. The form is to be completed, depending on the State, by one (1) or both of the parents/guardians and to be submitted to the physician prior to any medical procedure.

States that Require Parental Consent

*Requires Parent/Guardian Notarization

**Requires Both Parents

How to Write

Download in Adobe PDF.

Step 1 – The Parties – Enter the following information:

  • The authorizing parent’s/parents full name(s)
  • The minor daughter’s full name
  • Submit the name of the physician who shall be granted permission to perform the procedure

Step 2 – Parent(s)/Guardian/Conservator Acknowledgment – The person or persons who shall grant permission for medical professionals, must read the statement and agree to the understanding of felonious activity – Signature(s)must be applied before a notary public.

  • Parent(s)/Guardian/Conservator must acknowledge their understanding by entering their signature into the line provided
  • Enter the date of the consenting Parent(s)/Guardian/Conservator’s signature(s) – in mm/dd/yy format

Step 3 – Notarization – Signature(s) – The document must be signed in the presence of a Notary Public so that it may be effective –

  • Once the notary public has had the opportunity to witness the appropriate signatures, the notary shall enter all of the states required information
  • In acknowledgment, the notary shall apply their (notary’s) signature and affix the official seal or stamp

Step 4 – Required Attachments – The Parent(s)/Guardian/Conservator, must attach the following documentation before submission to the Physician:

  • Provide a copy of the consenting party’s government issued identification
  • Submit any written documentation that shall establish the parental relationship to the pregnant minor female

Step 5 – Physician Statement – (required) – This information must be provided by the physician only:

  • The physician must read the brief statement
  • Enter the physician’s name
  • The physician must provide their signature while in the presence of the parent(s)/guardian/conservator(s)
  • Date the physician’s signature – mm/dd/yy format
  • Once the physician has completed this section, the parent(s) party(ies) will be required to initial the box, in witness

Once the document has been completed, to secure the legal protection of the Parent(s)/Guardian/Conservator, all signatories must receive copies of the document for personal record keeping purposes.