Consent By Proxy For Minor (Permission To Treat Form) printable pdf download

Practice Limited to Allergy, Asthma & Immunology

Adult and Pediatric

CONSENT BY PROXY FOR MINOR (Permission to Treat Form)

I, Printed Name of Parent/Guardian, __________________________________________________ authorize

Name of Proxy: ______________________________________ Relationship to Minor(s) __________________

Address: _______________________________ ______ __________ as proxy decision maker for consenting to

routine medical care for my child(ren) listed below. Additionally, protected patient health information may

be shared with the proxy to facilitate informed decision making.

Child’s Name: ______________________________________

DOB: __________________________

Child’s Name: ______________________________________

DOB: _________________________

Limitation

Identify any limitations on the kinds of medical serves for proxy cannot consent. If none, state “none”.

______________________________________________________________________________________________

This authorization is valid for six (6) months from the date of signing and may be revoked at any time

providing written notice of revocation. I understand I cannot revoke this authorization retroactively for

treatment already provided.

I understand that instructions or information given to Responsible Party bringing in patient for visit,

treatment, medication(s) will be the only information given and parent will not be called separately with

information from this office. I understand that Responsible Party must be 18 years or older.

□

I authorize my underage child/patient (16 or 17) to bring themselves in for treatment and they have the

ability to understand the risks and benefits of treatment.

If the nature of the medical care is not routine, please try to contact me at the following telephone numbers.

If you are unable to contact me, you may rely on the proxy decision maker for consent.

Signature of Parent/Guardian: _________________________________ Date: ___________________________

Telephone Number(s): _______________________ ________________________ ________________________

705 S. Dobson Rd.

8140 E. Cactus Rd., Ste 710

4852 E. Baseline Rd, Ste 101

348 E. Virginia Ave.

Chandler, AZ 85224-5657

Scottsdale, AZ 85260-5265

Mesa, AZ 85206-4604

Phoenix, AZ 85004-1208

Phone: 480.897-6992

Phone:

480.344.4460

Phone:

480.346.4680

Phone:

602.266.4114

Fax:

480.752.1757

Fax:

480.344.4465

Fax:

480.346.4685

Fax:

602.274.5225

Consent By Proxy For Minor (Permission To Treat Form)

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