Authorization To Consent To Health Care For Minor Form - North Carolina
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1NORTH CAROLINA
AUTHORIZATION TO CONSENT TO HEALTH CARE FOR MINOR
I, ____________, of ____________ County, ____________, am the custodial parent having
legal custody o f____________, a minor child, age ______, born ________, 20___.
I authorize____________, an adult in whose care the minor child has been entrusted, and who
resides at____________, to do any acts which may be necessary or proper to provide for the
health care of the minor child, including, but not limited to, the power (i) to provide for such
health care at any hospital or other institution, or the employing of any physician, dentist, nurse,
or other person whose services may be needed for such health care, and (ii) to consent to and
authorize any health care, including administration of anesthesia, X-ray examination,
performance of operations, and other procedures by physicians, dentists, and other medical
personnel except the withholding or withdrawal of life sustaining procedures.
[Optional: This consent shall be effective from the date of execution to and including
____________, 20___].
By signing here, I indicate that I have the understanding and capacity to communicate health care
decisions and that I am fully informed as to the contents of this document and understand the full
import of this grant of powers to the agent named herein.
_________________________
_________________________
Custodial Parent
Date
STATE OF NORTH CAROLINA COUNTY OF NC GENERAL STATUTES - Chapter 32A 26
On this ________ day of__________, 20___, personally appeared before me the named
__________________, to me known and known to me to be the person described in and who
executed the foregoing instrument and he (or she) acknowledges that he (or she) executed the
same and being duly sworn by me, made oath that the statements in the foregoing instrument are
true.
_________________________
Notary Public
My Commission Expires: _________________________
(OFFICIAL SEAL).
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