Medical Authorization Form (Consent For Patient Unaccompanied By An Adult) printable pdf download

Medical Authorization Form (Consent For Patient Unaccompanied By An Adult)

Medical Authorization Form

Consent for Patient Accompanied by Adult Other than Parent/Legal Guardian

The Medical Authorization Form is used when someone besides a legal parent or guardian would need to accompany the patient

to an appointment. (i.e. a grandparent, nanny, aunt, step parent, etc.) Please complete a separate authorization form for each

authorized individual (or couple) and each child.

I, _________________________________________, on ________________, give ____________________________________,

Parent/Guardian’s Name

Today’s Date

Substitute Authority’s Name

__________________________________________ permission to make medical decisions for my child,

Relationship(s) to Child

__________________________________________ (_______/_______/_______) for the time period of

Child’s Full Name

Date of Birth

______________________________________________.

Give specific dates of validity or write “Indefinitely”

_____________________________________________

Parent/Guardian Signature

Consent for Patient Unaccompanied by an Adult

I, _________________________________________, on ________________, give my permission for my underage child (16 to 18

Parent/Guardian’s Name

Today’s Date

years old or older), _________________________________________ (_______/_______/_______) to be seen and make

Child’s Full Name

Date of Birth

medical decisions recommended by Cornerstone Pediatric & Adolescent Medicine for the period of:

_________________________________.

Give specific dates of validity or write “Indefinitely”

Limitations: Identify any limitations on the kinds of medical services for which this consent by proxy is invalid.

_________________________________________________________________________________________________________

_____________________________________________

Parent/Guardian Signature

Medical Authorization Form (Consent For Patient Unaccompanied By An Adult)