Medical Treatment Authorization And Consent Form printable pdf download

Medical Treatment Authorization And Consent Form

MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM

The following form is designed for those situations where minors are unaccompanied by either

biological parent(s) or legal guardians. This “Medical Treatment Authorization and Consent Form” gives

authority to a designated adult to arrange for medical/dental care of a minor. This is extremely

important, in that, medical/dental care cannot be provided to a minor without approval by the biological

parent(s) or legal guardians, unless there is written consent authorizing an agent to give approval.

________________________________________________________________________________

Name of Minor Child

Date of Birth

The Undersigned do hereby authorize Renée L. I. Owen, DDS, PC as agent for the Undersigned to

consent to any X-Ray, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care

for the above named minor which is deemed advisable by and to be rendered under the general or

special supervision of any physician and/or surgeon, licensed under the Provision of Medicine Practice

Act or of any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is

rendered at the office of said physician or dentist, at a hospital, or elsewhere.

________________________________________________________________________________

Name of Designated Adult

Relationship

________________________________________________________________________________

Name of Designated Adult

Relationship

________________________________________________________________________________

Name of Designated Adult

Relationship

________________________________________________________________________________

Printed Name of Biological Parent or Legal Guardian

________________________________________________________________________________

Biological Parent or Legal Guardian Signature

Date

________________________________________________________________________________

Signature of Witness

Medical Treatment Authorization And Consent Form