Patient Information Form Page 4
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7"Personal Doctor For Your Child"
ANDREW M. BLUMBERG, M.D.
PEDIATRICS •
INFANTS,
CHILDREN AND
ADOLESCENTS
Several times each year, our younger patients are in
need of medical
treatment
at
our office or at the hospital while their parents have
unexpectedly left town.
In order to prevent undue delay in rendering medical care
, this form
authorizes
treatment to a minor when no legal guardian is present.
AUTHORIZATION TO CONSENT TO TREATMENT
OF A MINOR
(I) (We), the undersigned parent(s) or guardian to
_ _ _
__
__ _ _ _
a minor, do hereby authorize Andrew M. Blumberg, M.D. as
agent for the
undersigned
to consent to any x-ray examination, medical diagnosis or
treatment and
hospital care
which is deemed advisable by, and is to be rendered at the office
or hospital.
It is understood that this authorization is given in advance
of any
specific
diagnosis, treatment or hospital care being required but is
given to provide
authority
and power on the part of our aforesaid agent to give specific
consent to any
and all
such diagnosis, treatment or hospital care which the
aforementioned physician
in the
exercise of his/her best judgement may deem advisable.
This authorization is given pursuant to the provisions of
Section 25.8 of
the Civil
Code of California.
Dated: _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
Fa.ther:
_ _ _ _
__ _ _
__ _ _ _ _
_
Witness:
_ _ _ _ _ _ _ _ _ _ _ _ _
_
Mother:
_ _ _
__
__ _ _ _ _ _ _
_
Witness:
_ _ _ _ _ _ _ _ _ _ _ _ _
_
Legal Guardian: _
_ _ _ _
__ _ _ _ _
Sand
Canyon Medical Center
16100 Sand
Canyon
Avenue,
Suite 350. Irvine,
California
92618
Tel
:
(949)
450-0077 •
Fax:
(949)
450-1277
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