*Required fields are marked with an asterisk.

Parental Consent for Treatment of Minor Children

 Parental Consent for Treatment of Minor Children (pdf)


Parental Consent for Treatment of Minor Children (docx)

(Click the blue link above then click "open" and "print")

  This form requires a signature.

Please print, sign and return:

                               by mail:    HIMG  Portal for Patients                          

                   5170 U.S. Rt. 60 East

                    Huntington, WV 25705


            by fax:     304-697-0856           


   by email:   patientportaladmins@uhswv.com