Power Of Attorney Over A Minor Child - Health Care (Page 3 of 5) in pdf

Power Of Attorney Over A Minor Child - Health Care Page 3

POWER OF ATTORNEY OVER A MINOR CHILD – HEALTH CARE

STATE OF ARIZONA

)

County of Maricopa

)

I, _____________________

of:

Parent/Guardian Name

______________________

Address

______________________

City

State

Zip Code

do solemnly swear that:

I am the natural parent of

Name of Child(ren)

Date of Birth

I authorize

____________________________

Name of person authorized

____________________________

Address

____________________________

City

State

Zip Code

to assume power of attorney over my minor children, in accordance with the

provisions of Arizona Revised Statutes, Section 14-5104, which states as follows:

A parent or guardian of a minor or incapacitated person, by properly

executed power of attorney, may delegate to another person, for a period

not exceeding six months, any powers he may have regarding care,

custody or property of the minor child or ward, except power to consent to

marriage or adoption of the minor.

I further appoint____________________ as my true and lawful attorney-in-fact,

Name of Person Authorized

for me and in my name, place and stead, for the purpose of giving or refusing

consent to any medical treatment, including x-ray examination, anesthetic, medical

or surgical diagnosis and treatment, hospital admission, or other related health care

needs; to obtain medical and dental treatment, whether an emergency or not, and to

consent and give permission for any operations, treatment or health care. Such

attorney-in-fact is authorized to sign any and all forms required by health care

agencies to indicate parental permission on behalf of each child.

Power Of Attorney Over A Minor Child - Health Care Page 3