Authorization For Medical Treatment Of Minor


Authorization for Medical Treatment of Minor
Child: __________________________________ Date of Birth ________________
Child: __________________________________ Date of Birth ________________
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
This authorization if effective commencing _________________________ and
expiring _________________________.
(Parent or Legal Guardian)
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 ____________________


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Parent category: Medical