Medical Authorization For Minors

ADVERTISEMENT

Medical Authorization for Minors
I, __________________________________, the parent or legal guardian of the below mentioned minor
child(ren), do hereby grant my authorize and consent to seek medical care to any one or more of the below
mentioned adults whose care the minor child(ren) has been entrusted to act as agent(s) for myself in my
absence. Medical care includes, but is not limited to, any treatment of illnesses, diseases, well care,
immunizations and medical advice. Further, I give permission for the agent below to pick up written
prescriptions for controlled substances in my absence.
CHILD
DATE OF BIRTH
AGENT NAME
RELATIONSHIP
ADDRESS
PHONE
It is understood that this authorization is given in advance of any specific diagnosis, treatment or care being
required but is given to provide authority and power on the part of the aforesaid agent(s) to give specific
consent to any and all such diagnosis, treatment or hospital care which a physician or healthcare provider in the
exercise of his or her best judgment may deem advisable.
This authorization shall remain in effect until ________________________ or until the child(ren) reach 18
Month/Day/Year
years of age.
Signature of Parent
or Legal Guardian: ______________________________________
Printed Name:
______________________________________
Date:
______________________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go