Medical Treatment Authorization And Consent Form printable pdf download

Medical Treatment Authorization and Consent Form

The following form is designed for those situations when minors are unaccompanied by either parent or a legal

guardian. This form gives authority to a designated adult to arrange for medical care for a minor in the event of an

emergency. Medical care cannot be provided to a minor without approval by the parents or legal guardians unless

there is written consent authorizing an agent to give approval.

_________________________________________________________________________________

Minor’s Full Name

_________________________________________________________________________________

Minor’s Street Address

_________________________________________________________________________________

City, State, Zip Code

_________________________________________________________________________________

Minor’s Date of Birth

The undersigned do hereby authorize ___________________________________________ to consent to any

radiographic procedure, anesthetic, or medical, dental, or surgical treatment or hospital care for the above named

minor which is deemed advisable by and to be rendered under the supervision of any physician and/or surgeon

licensed under the Provision of Medicine Practice Act, or of any dentist licensed under the Dental Practice Act,

whether such treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere.

______________________________________ _____________________ ____________________________

Parent or Guardian Signature

Date

Printed Name

______________________________________ _____________________ ____________________________

Second Parent or Guardian Signature (if applies) Date

Printed Name

_________________________________________ ________________________________________________

Address of Parent(s)

City, State, Zip Code

________________________________________________

Home and Work Phone Numbers

________________________________________________ _________________________________________

Insurer

Account Number

________________________________________________ _________________________________________

Minor’s Physician

Physician Phone Number

Notary

State of _________________________

County of ______________________

SUBSCRIBED AND SWORN TO before me this _______ day of ________________, 20 _____

_______________________________________(Notary Public) My Commission Expires: ______________

Medical Treatment Authorization And Consent Form