Authorization For Medical Treatment Of Minor printable pdf download

Authorization For Medical Treatment Of Minor

Authorization for Medical Treatment of Minor

Child: __________________________________ Date of Birth ________________

I hereby declare that I have legal custody of above named minor child(ren).

I grant my authorization and consent for _______________________________

to issue consent for any transport, X-ray, anesthetic, blood transfusion, medication, or

other medical, dental, or surgical diagnosis, treatment, office or hospital care deemed

advisable by, and to be rendered under the general supervision of, any licensed

physician, surgeon, dentist, hospital or other medical professional or institution duly

licensed to practice in the state in which such treatment is to occur.

It is understood that this consent is given in advance of any specific diagnosis or

treatment being required, but is given to provide authority to the temporary guardian in

the exercise of their best judgment upon the advice of medical, dental or emergency

personnel.

This authorization if effective commencing _________________________ and

expiring _________________________.

______________________________________

________________________

(Parent or Legal Guardian)

(Date)

Certificate of Acknowledgment of Notary Public

STATE OF __________________

COUNTY OF ________________

This document was acknowledged before me

on ____________________ by ______________________________.

Notary _________________________________

Notary Public for the State of _______________

My commission expires ____________________

Authorization For Medical Treatment Of Minor