Power Of Attorney For Consent To Medical Care For A Minor

ADVERTISEMENT

Power of Attorney for Consent to Medical Care for a Minor
By signing this form, I (we) hereby authorize _____________________________________ to consent to
any medical care and treatment for ___________________________________ (Child) that is recommended
by a licensed healthcare provider to whom the Child is presented for treatment. In order to ensure that the
Child receives prompt medical care and treatment when necessary, I (we) hereby release any licensed
health care provider providing medical care to the Child in reliance of this form from liability relating to such
provider's acceptance of my (our) substitute care giver's consent.
This Power of Attorney is dated __________________________, ____________ and is valid for one year.
_____________________________ _________
______________________________ _________
Parent's Signature
Date
Second Parent's Signature (optional)
Date
_______________
_______________________________
___________________
Dated
Signature - Notary Public
My commission expires
Medical History
(Failure to complete any of the following does not impair the validity of this Power of Attorney
for consent to medical care for a minor.)
_________________________
________________________
________________________
Child's Name
Child's Birth Date
Allergies
_________________________
________________________
________________________
Religion
Blood Type
Date of Last Tetanus Shot
_________________________________________
_________________________________________
Previous Hospitalizations and Major Illnesses
Current Medications
_________________________
________________________
________________________
Pediatrician
Telephone
Other Important Information
Other Information
__________________________
__________________
__________________________________
Father's Name
Home Phone
Home Address
________________________________________
__________________________________
Place of Employment
Work Phone
________________________________________
__________________________________
Insurance Company
Policy Number
__________________________
__________________
__________________________________
Mother's Name
Home Phone
Home Address
________________________________________
__________________________________
Place of Employment
Work Phone
________________________________________
_________________________________
Insurance Company
Policy Number

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Power Of Attorney For A Minor Child Power Of Attorney For A Minor Child Legal
Power Of Attorney For A Motor Vehicle, Mobile Home Or Vessel - Florida Department Of Highway Safety And Motor Vehicles Power Of Attorney For A Motor Vehicle, Mobile Home Or Vessel - Florida Department Of Highway Safety And Motor Vehicles Legal
Form Hsmv 82053 -power Of Attorney For A Motor Vehicle, Mobile Home Or Vessel/hsmv 82040 - Application For Certificate Of Title With/without Registration Form Hsmv 82053 -power Of Attorney For A Motor Vehicle, Mobile Home Or Vessel/hsmv 82040 - Application For Certificate Of Title With/without Registration Legal
Arkansas Power Of Attorney For A Child Form Arkansas Power Of Attorney For A Child Form Legal
Form 82053 - Power Of Attorney For A Motor Vehicle, Mobile Home Or Vessel Form 82053 - Power Of Attorney For A Motor Vehicle, Mobile Home Or Vessel Legal
Power Of Attorney For Health Care Of A Minor Dependent Power Of Attorney For Health Care Of A Minor Dependent Legal
Power Of Attorney For Care Of A Minor Child Power Of Attorney For Care Of A Minor Child Legal
Power Of Attorney For Care, Custody Or Property Of Minor Child Power Of Attorney For Care, Custody Or Property Of Minor Child Legal
Power Of Attorney For Health Care - Sage Medical Group Power Of Attorney For Health Care - Sage Medical Group Legal
Medical Durable Power Of Attorney For Health Care Form - State Of Colorado Medical Durable Power Of Attorney For Health Care Form - State Of Colorado Legal

Related Categories

Parent category: Legal
Download
Go