Hw Form 145 - Consent To Treat Minor printable pdf download

Hw Form 145 - Consent To Treat Minor

I (We) of _______________________________________________________________________________

(Street Address)

(City, State & Zip)

(County)

Ohio, do hereby state that I am (we are) the natural parent(s) or legal guardian of

________________________________________, age ___________, birth date______________________

(Name of Child)

I (We) authorize ____________________________________________________________________to give

(Name of Person Taking Care of Child)

consent for medical care of said child. I (We) authorize Doctor ___________________________to provider all

necessary medical care and treatment for the child which the medical provider determines necessary for the

health and well-being of my (our) child.

This authorization is for the following period:__________________________ to _______________________

Parent/Guardian Signature _______________________ Parent/Guardian Signature____________________

Address _____________________________________ Address __________________________________

_____________________________________

__________________________________

Date ________________________________________ Date _____________________________________

Witnessed by:

Witness Signature _____________________________ Print Name ________________________________

Address _______________________________________________________________________________

Date ____________________________________________

OTHER INFORMATION

Allergies _______________________________________________________________________________

Date of Last Tetanus _______________________________________

This authorization is not for immumizations

HW Form 145 (3/99)

Hw Form 145 - Consent To Treat Minor