Parental Authority To Consent To Treatment Of Minor And Release Of Liability Agreement Template (Page 2 of 2) in pdf

Parental Authority To Consent To Treatment Of Minor And Release Of Liability Agreement Template Page 2

MEDICAL INFORMATION

Insurance Company: ___________________________________________________________________

Claim Office Address: __________________________________________________________________

Claim Office Telephone: ___________________________________

Policy # ________________________________________

Special Medical Conditions of Minor (Such as Diabetes, Allergic reactions): ____________________________

________________________________________________________________________________________

Family Doctor: __________________________________________ Phone: _________________________

Address: __________________________________ City ______________________ Zip ________________

Family Code of California

Section 6910

The parent, guardian, or caregiver of a minor who is a relative of the minor and who may authorize medical care or

dental care under Section 6550, may authorize in writing an adult whose care a minor has been entrusted to consent to

medical or dental care, or both, for the minor.

Section 6901

“Dental Care” means X-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care by

a dentist licensed under the Dental Practice Act.

Section 6902

“Medical Care” means X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care

under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed

under Medical Practice Act.

Health & Safety Code

Section 1283(a)

No health facility shall surrender the physical custody of a minor under 16 years of age to any person unless such

surrender is authorized in writing by the child’s parent, the person having legal custody of the child, or the caregiver of the

child who is a relative of the child and who may authorize medical care and dental care under Section 6550 of the Family

Code.

Parental Authority To Consent To Treatment Of Minor And Release Of Liability Agreement Template Page 2