Permission To Treat Minors Form printable pdf download

PERMISSION TO TREAT MINORS

I (We), _________________________________, am (are) the parent(s) or legal guardian(s) of:

______________________________DOB: ____________ grant to ________________________

(Name and relationship to patient)

the authority to consent to treatment of the above named minor. Should his/her condition

____________________________________(list condition) require treatment, the above named

person having physical custody or responsibility for the care of the minor in need may bring this

consent to the physician or hospital. This permission may include transportation and/or admission to

an appropriate health care facility.

I (We) understand medical or surgical treatment can include diagnostic laboratory or radiology

testing, injections, medical care, or surgery considered necessary in the situation We will take

financial responsibility as the parent or legal guardian for any treatment rendered. I (We) set no

limitations on treatment of the above named minor(s) other than:

_____________________________________________________________________________

I (We) understand that reasonable attempts will be made to contact me (us) in the event of an

emergency. This authorization is effective from the date of signature until the following date:

________________ (not to exceed 12 months from date of signature).

x____________________________________

x______________________________________

Signature of parent/legal guardian

_________ ___________________________

___________ __________________________

Date

Relationship to Child

Date

Relationship to Child

Telephone #(s) you can be reached at: _________________________________________

Additional Information

Child’s Address _____________________________________

Primary Care Physician ____________________________

City/State/Zip _________________Phone ______________

City/State/Zip __________________Phone _______________

Insured Work Place _________________________________ Spouse’s Work Place _________________________________

Address _____________________ Phone _______________ Address _______________________ Phone ______________

Health Insurance Company ______________________________________________________________________________

Policy number ______________________________________ Policy Group number _________________________________

Name of Policy Holder_______________________________ Policy Holder date of birth: _____________________________

Name and Address of Pharmacy ___________________________________________________Phone _________________

Other Contact ______________________________________ Address/Phone ______________________________________

Permission To Treat Minors Form