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Medical Treatment of Minors

  • If your child needs medical, dental, health or hospital services, you as a parent must give permission: It is the law.
  • True emergency is determined by a physician. When unable to reach a parent, a PHYSICIAN MAY PROCEED WITH TREATMENT. If not a true emergency, consent is needed by Parent /Guardian. This authorization form can be very important.
  • When away from home, leave forwarding information with a babysitter or other adult.
  • A person over 18 years of age should be made responsible for your child in your absence. This authorization form will allow necessary treatment for your child. If necessary, they should present this completed form to the physician, dentist or hospital representative.
  • Fill out this form carefully. Have your signature witnessed by an adult other than the person responsible for you child.
Names of minors
Date of Birth

Indicate allergies, special conditions and current medications
     
     
     

I/We being the parent (s) or legal guardian of the above-names minor (s), do hereby appoint:

Adult Name
Address
Phone
______________
_________________________________
_________
 
_________________________________
  

to act in my/our behalf in authorizing unexpected medical, dental, surgical care and hospitalization for the above-named minor (s) during the period of my/our absence, from:

Month/ Day/ Year ___ /___ /______
through
Month/ Day/ Year ___ /___ /______

This document shall be presented to a physician, dentist or appropriate hospital representative at such time as unexpected medical, dental, surgical care or Hospitalization may be required.

Parent/Guardian

Parent/Guardian
Signature _______________________________ Signature ________________________________
Address_________________________________ Address__________________________________
Date ___________________________ Date ___________________________
Witness
Witness
Signature ________________________________ Signature ________________________________
Address__________________________________ Address__________________________________
Date ___________________________ Date ___________________________

Hospitalization coverage for the above-named minor (s):

Insurance Company
ID or Contract #
_____________________________________
______________________________________
Family Physician
Phone #
_____________________________________
______________________________________