Authorization For Minor'S Medical Treatment Form
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AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT
Child
Full Legal Name:
_____________________________________________________________________________
Date of Birth: __________________________
Age: ___________ Gender: ___________
Female
Doctor’s Information
Doctor’s Name:
_____________________________________________________________________________
Doctor’s Address:
_____________________________________________________________________________
Doctor’s Office Phone: ____________________ Doctor’s Emergency Phone: _______________
Medical Insurer/Health Plan: __________________________
Policy #: __________________
Allergies to Medications:
_____________________________________________________________________________
Allergies (Other):
_____________________________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
_____________________________________________________________________________
Note any other significant medical information:
_____________________________________________________________________________
_____________________________________________________________________________
Dentist’s Information
Dentist’s Name:
_____________________________________________________________________________
Dentist’s Address:
_____________________________________________________________________________
Dentist’s Office Phone: ____________________ Dentist’s Emergency Phone: _______________
Dentist’s Insurer/Health Plan: __________________________
Policy #: __________________
Parent(s)/Legal Guardian(s):
Parent #1:
Name:
_____________________________________________________________________________
Address:
_____________________________________________________________________________
Home phone: __________________________
Work phone: __________________________
Cell phone: ____________________________
Pager: _______________________________
Email: ________________________________
Additional Contact Information:
_____________________________________________________________________________
_____________________________________________________________________________
Parent #2:
Name:
_____________________________________________________________________________
Address:
_____________________________________________________________________________
Home phone: __________________________
Work phone: __________________________
Cell phone: ____________________________
Pager: _______________________________
Email: ________________________________
Additional Contact Information:
_____________________________________________________________________________
_____________________________________________________________________________
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