Minor Medical Treatment Authorization Form

MINOR MEDICAL TREATMENT AUTHORIZATION FORM

I hereby authorize the physicians at Immediate MD, in our absence, to provide required

medical treatment, in the opinion of the provider acting on behalf of our child.

Patient Name:

DOB:

Legal Parent/Guardian

Name:___________________________________________________________

Legal Parent/Guardian

Signature:________________________________________________________

Contact Number:__________________________________________Date:______________

I also authorize the following persons to authorize medical treatment for the above named

child(ren).

Full Name:

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Parent category: Business