Authorization For Medical Treatment Form - Lake Ray Hubbard Pediatrics printable pdf download

Authorization for Medical Treatment

Lake Ray Hubbard Pediatrics, PA

If your child needs medical, dental or hospital services, a parent must

how to reach you at all times. And when you know you will be hard to

give permission. It's the law. What about times when you cannot be

reach, you can give permission to other adults. They can then act for you

reached for permission? A child may be treated without parental

by permitting your child to be treated if unexpected care is needed.

consent when a physician determines a true emergency exists. That

means the doctor determines the child needs immediate medical care

This is a legal document. With it you may appoint relatives, friends,

and that an attempt to obtain parental consent would result in a delay

teachers clergy, neighbors - anyone who is over 18 years of age - to be

which would increase the risk to the child's life or health.

responsible for your children when you are away from them. It is

especially important to prepare this form for the occasions, when you know

Except in a true emergency, care may be ordinarily rendered to a

it will be hard to contact you.

child only with the consent of the parent or legal guardian.

Sometimes a child may need unexpected care which is not, however,

Fill out this form. give it to the adult(s) you have named to act on your

a true emergency. In such cases, making an effort to contact a parent

behalf. If your child needs unexpected medical treatment. the responsible

for permission can delay treatment and create unnecessary anxious

adult(s) should present this document to the appropriate person- physician.

moments for the child.

dentist or hospital representative.

You can prepare for unexpected care your children might need when

you are away from home. To do this, make sure babysitters know

AUTHORIZATION FOR MEDICAL TREATMENT OF MINORS

Name of Minor(s)

DOB

Allergies/ Special Conditions

I/ We, being the parent(s) or legal guardian(s) of te above named minor(s), do hereby appoint:

Name

Address

Phone #

To act in my/our behalf in authorizing unexpected medical, dental, surgical care and hospitalization for the above named minor(s) during the preiod of

my/our absence, from:

This document shall be presented to a physician, dentist or appropriate hospital representative at such time as unexpected medical, dental, surgical, care

or hospitalization my be required.

Signature of Parent / Guardian

Address

Signature of Parent / Guardian

Address

Signature of Witness

Address

Signature of Witness

Hospitalization Coverage for above Named Minor(s)

Insurance Company or Government Program ID or Contact #

Family Physician:

Name: