|
Parenting
- Sample Authorization to Treat a Minor Form
AUTHORIZATION
TO TREAT A MINOR
This consent shall remain
effective until
We, the undersigned parents
of
(DOB
), a minor, do hereby authorize and consent to any
x-ray examination, anesthetic, medical or surgical diagnosis
rendered under the general or special supervision of any member
of the medical staff and emergency room staff licensed under the
provisions of the Medicine Practice Act, of a Dentist licensed
under the provisions of the Dental Practice Act, and on the
staff of any acute general hospital holding a current license to
operate a hospital from the State of California Department of
Public Health. It is understood that this authorization is given
in advance of any specific diagnosis, treatment or hospital care
being required but is given to provide authority and power to
render care which the aforementioned physician in the exercise
of his best judgment may deem advisable. It is understood that
effort shall be made to contact the undersigned prior to
rendering treatment to the patient, but that any of the above
treatment will not be withheld if the undersigned cannot be
reached.
List any restrictions:
NO SURGICAL PROCEDURES UNLESS
REQUIRED AS A LIFE-SAVING MEASURE.
Father:_______________________________________________________
Date:___________
Mother:_______________________________________________________
Date:___________
ADDRESS:
Allergies to Drugs or Foods:
None Known as of
Any Special Medications or
Pertinent Information:
Telephones Where Parents May Be
Reached
Father:
: Cell
; Office ;
Home:
Mother:
: Cell
; Office ;
Home:
Pediatrician:
Address:
Insurance Policy Information for
Child:
|
