Parental Authorization To Treat Minor Child - Wake Forest Baptist Health printable pdf download

Parental Authorization To Treat Minor Child - Wake Forest Baptist Health

NAME: ____________________________

MRN:______________________

(Patient Label)

Parental Authorization to treat Minor Child

When not accompanied by Parent or Guardian

We must have permission from a child’s parent or guardian before providing medical services when the child

is accompanied by someone other than the parent or legal guardian. If you feel there may be an occasion

where your child will be brought by a relative, sitter, etc., please fill out the following information for us to

include with your child’s records.

Patient’s Name_________________________________________ Date of Birth__________________

The following persons have my permission to authorize medical care for my child and sign the encounter form

signifying my responsibility for payment:

Name

Relationship

□

Patient listed above may present unaccompanied by an adult.

________________________________________________

_______________

______________

Signature of Parent or Legal Guardian

Date

Time

_________________________________________________

_______________

______________

Witness Signature

Date

Time

_________________________________________________

_______________

______________

Interpreter Signature/ID# (if applicable)

Date

Time

This authorization will be in effect until changed by the Parent or Legal Guardian above

Rev 12/14

Chart Copy

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Parental Authorization To Treat Minor Child - Wake Forest Baptist Health