Authorization To Consent To Treatment Of Minor Form printable pdf download

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR

(I) (We), the undersigned parent(s)/guardian(s) of __________________________, a

minor, do hereby authorize University of California, Berkeley Health Services or

attending medical personnel as agent(s) for the undersigned to consent to any X-ray

examinations, anesthetic, medical or surgical diagnosis or treatment, or hospital care

which is deemed advisable by, and is to be rendered under the general or special

supervision of, any physician and/or surgeon licensed under the provisions of the Medical

Practices Act, California Business and Professions Code §2000 et. seq.; or any X-ray

examination, anesthetic, dental or surgical diagnosis or treatment, or hospital care which

is deemed advisable by, and is to be rendered under the general or special supervision of,

any dentist licensed under the provisions of the Dental Practices Act, California Business

and Professions Code §1600 et. seq.

It is understood that this authorization is given in advance of any specific diagnosis,

treatment or hospital care to provide authority and power on the part of our aforesaid

agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care

which aforementioned physician or dentist, in the exercise of his/her best judgment, may

deem advisable. This authorization is given pursuant to the provisions of California

Family Code §6910.

(I) (We) hereby authorize any hospital, which has provided treatment to the above-named

minor pursuant to the provisions of California Family Code §6910, to surrender physical

custody of such minor to (my) (our) above-named agent(s) upon the completion of

treatment. This authorization is given pursuant to California Health and Safety Code

§1283.

These authorizations shall remain effective until ______________, 20___, unless sooner

revoked in writing delivered to said agent(s).

Signed: __________________________________

_______________________________

Date of Signature

Parent/Guardian

Address: __________________________________

City:

__________________ State:__________

Phone No.: Home (____) ___________________

Work (____) ___________________

Cell (____) ____________________

3/7/08

Authorization To Consent To Treatment Of Minor Form