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NOTE: THE FORMS AVAILABLE IN THIS ARCHIVE ARE SUBJECT TO OUR TERMS OF USE AND ARE NOT A SUBSTITUTE FOR THE ADVICE OF AN ATTORNEY. LEGAL ADVICE OF ANY NATURE SHOULD BE SOUGHT FROM COMPETENT LEGAL COUNSEL IN THE RELEVANT JURISDICTION. THESE FORMS ARE PROVIDED "AS IS."
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AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT

 

Child

Full Legal Name: ___________________________________________________________________
Date of Birth: _______________________           Age: ___________             Gender: ___________

 

Doctorís Information
Doctorís Name: ____________________________________________________________________

Doctorís Address: __________________________________________________________________

Doctorís Office Phone: ____________________ Doctorís Emergency Phone: __________________

Medical Insurer/Health Plan: __________________________
    Policy #: ______________________ 
Allergies to Medications: _____________________________________________________________
Allergies (Other): ___________________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
_________________________________________________________________________________
Note any other significant medical information:
_________________________________________________________________________________
_________________________________________________________________________________

 

Dentistís Information
Dentistís Name: ____________________________________________________________________

Dentistís Address: __________________________________________________________________

Dentistís Office Phone: ____________________ Dentistís Emergency Phone: __________________

Dentistís Insurer/Health Plan: __________________________    Policy #: _____________________

 

Parent(s)/Legal Guardian(s):

 

Parent #1:
Name: ___________________________________________________________________________

Address:  ________________________________________________________________________

Home phone: __________________________       Work phone: ____________________________
Cell phone: ____________________________      Pager: _________________________________

Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________

 
Parent #2:

Name: ___________________________________________________________________________

Address:  ________________________________________________________________________

Home phone: __________________________       Work phone: ____________________________
Cell phone: ____________________________      Pager: _________________________________

Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________

 

Alternate contact in the event Parent(s)/Legal Guardian(s) cannot be reached:
Name: ___________________________________________________________________________

Address:  ________________________________________________________________________

Home phone: __________________________       Work phone: ____________________________
Cell phone: ____________________________      Pager: _________________________________

Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________


 

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S) 

 

I do hereby solemnly swear that I have legal custody of the aforementioned minor child.

I grant my authorization and consent for _________________________________________ (hereafter ďSupervising AdultĒ) to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.

It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

This authorization is effective commencing on the ______day of ____________________, 20_____ and expiring on the ______day of ____________________, 20____.
 

Signed this ______day of____________________, 20 ____.

 


______________________________________
Parent #1ís Signature

 


______________________________________
Parent #2ís Signature

 


CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

 

STATE OF __________________
COUNTY OF ________________

 

This document was acknowledged before me on ______________________ [date] by ________________________________________________ [name of principal]. 

 

[Notary Seal, if any]: 

_______________________________
(Signature of Notarial Officer)
 
Notary Public for the State of ______________
 
My commission expires: __________________


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