Authorization To Treat Minor Form

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Authorization for Treatment of Minors
Names of Minor Children
Birth date
Allergies or Special Conditions
____________________________/______________________________
Parent Names:
I/We, the biological parent(s) or legal guardians(s) of the above named children give permission for IHA
to provide medical treatment as necessary for my child’s health, including evaluations, perform diagnostic
procedures and provide medical treatment as deemed necessary by the Attending Provider. I authorize IHA
or their representatives to act on my behalf, in providing my child such care when I cannot be
contacted.
We/I will be responsible to provide IHA with up to date pertinent history and condition information prior
to each appointment and to make arrangements to receive follow up instructions and treatment plans.
If such efforts to communicate with me are unsuccessful, I authorize Integrated Health Associates to take
appropriate action and give consent on my behalf as his/her judgment dictates.
AND, In addition I authorize the following adults and step-parents to make such medical treatment
decisions as listed above, in my absence:
Name: ________________________________Relationship:____________________Phone____________
Name: ________________________________Relationship:____________________Phone____________
Name: ________________________________Relationship:____________________Phone____________
This authorization includes administering vaccinations as deemed appropriate by the Attending Provider. This authorization
may be cancelled at any time, and shall remain active until such time it is cancelled in writing, or a new updated authorization is
received. I/We understand that we are responsible for all reasonable charges in connection with the care and treatment of my
children listed above.
Authorization Signature: ________________________________________ Date:_______________________
Parent/Legal Guardian Full Name: ___________________________________Date of Birth: _______________
Address:____________________________________________________ Phone Number:__________________
ice Location:____________________________
Witness:___________________________
Off
This is a legal document. This form shall be presented to a physician or appropriate hospital representative at such time as medical,
hospital, or immunization care may be required. (Legal Guardianship requires written proof).

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