Consent / Authorization For Medical Treatment Of Minors
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1C
/
A
M
T
M
ONSENT
UTHORIZATION FOR
EDICAL
REATMENT OF
INORS
As a general rule, minors cannot consent to medical treatment. Therefore, except in special
situations (e.g., emergency treatment or emancipation), a physician must obtain the consent of
the parent(s) or legal guardian to treat a minor. Please complete this form. That way we will
know that you have authorized the designated person(s) to make medical decisions in your
absence.
In the event the undersigned parent / guardian of:
Patient Name: ____________________________________ Date of Birth: _________________
is absent during a medical appointment, they do hereby empower and grant to:
_______________________ ______________________________________________________
Name
Address
_______________________ ___________________________ __________________________
Relationship to patient
Phone Number
Alternate Phone Number
_______________________ ______________________________________________________
Name
Address
_______________________ ___________________________ __________________________
Relationship to patient
Phone Number
Alternate Phone Number
_______________________ ______________________________________________________
Name
Address
_______________________ ___________________________ __________________________
Relationship to patient
Phone Number
Alternate Phone Number
the right to consent permission of any medical treatment for the minor from a qualified and
licensed physician of Kids Health Partners, LLC.
This authorization shall be valid until I provide revocation to Kids Health Partners, LLC in writing.
I do hereby indemnify and hold harmless the physicians and other persons who act in reliance
upon this authorization.
Executed this _____ day of ___________, 20_____. _________________________________
Signature of Parent / Guardian
Parent/Guardian Contact Information:
_________________________________ ___________________ ___________________
Name of Parent / Guardian Phone Number Alternate Phone Number
_________________________________ ___________________ ___________________
Name of Parent / Guardian Phone Number Alternate Phone Number
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