Medical Treatment Of Minors Form
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1Medical Treatment of Minors
•
If your child needs medical, dental, health of hospital services, you as a parent must give permission: It is
the law.
•
True emergency is determined by a physician. When unable to reach a parent, a PHYSICIAN MAY PROCEED
WITH TREATMENT. If not a ture emergency, consent is needed by Parent /Guardian. This authorization from
can be very important.
•
When away from home, leave forwarding information with a babysitter or other adult.
•
A person over 18 years of age should be made responsible for your child in your absence. This authorization
from will allow necessary treatment for your child. If necessary, they should present this completed form to
the physician, dentist or hospital representative.
•
Fill out this form carefully. Have your signature witnessed by an adult other that the person responsible for
you child.
Indicate allergies, special conditions
Names of minors
Date of Birth
and current medications
I/We being the parent (s) or legal guardian of the above-names minor (s), do hereby appoint:
Adult 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 period of my/our absence, from:
Month/ Day/ Year _____ /___ /_____
through
Month/ Day/ Year _____ /___ /_____
This document shall be presented to a physician, dentist or appropriate hospital representative at such time as
unexpected medical, dental, surgical care or Hospitalization may be required.
Parent/Guardian
Parent/Guardian
Signature __________________________________
Signature ___________________________________
Address____________________________________
Address_____________________________________
Date ___________________________
Date ___________________________
Witness
Witness
Signature __________________________________
Signature __________________________________
Address____________________________________
Address____________________________________
Date ___________________________
Date ___________________________
Hospitalization coverage for the above-named minor (s):
Insurance Company
ID or Contract #
_____________________________________
_______________________________________
Family Physician
Phone #
_____________________________________
______________________________________
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