Authorization To Consent To Treatment Of Minor Form

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AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR
(I) (We), the undersigned parent(s)/guardian(s) of __________________________, a
minor, do hereby authorize University of California, Berkeley Health Services or
attending medical personnel as agent(s) for the undersigned to consent to any X-ray
examinations, anesthetic, medical or surgical diagnosis or treatment, or hospital care
which is deemed advisable by, and is to be rendered under the general or special
supervision of, any physician and/or surgeon licensed under the provisions of the Medical
Practices Act, California Business and Professions Code §2000 et. seq.; or any X-ray
examination, anesthetic, dental or surgical diagnosis or treatment, or hospital care which
is deemed advisable by, and is to be rendered under the general or special supervision of,
any dentist licensed under the provisions of the Dental Practices Act, California Business
and Professions Code §1600 et. seq.
It is understood that this authorization is given in advance of any specific diagnosis,
treatment or hospital care to provide authority and power on the part of our aforesaid
agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care
which aforementioned physician or dentist, in the exercise of his/her best judgment, may
deem advisable. This authorization is given pursuant to the provisions of California
Family Code §6910.
(I) (We) hereby authorize any hospital, which has provided treatment to the above-named
minor pursuant to the provisions of California Family Code §6910, to surrender physical
custody of such minor to (my) (our) above-named agent(s) upon the completion of
treatment. This authorization is given pursuant to California Health and Safety Code
§1283.
These authorizations shall remain effective until ______________, 20___, unless sooner
revoked in writing delivered to said agent(s).
Signed: __________________________________
_______________________________
Date of Signature
Parent/Guardian
Address: __________________________________
City:
__________________ State:__________
Phone No.: Home (____) ___________________
Work (____) ___________________
Cell (____) ____________________
3/7/08

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