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Authorization for Minor's Medical Treatment

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					This Authorization for a Minor’s Medical Treatment is executed by the natural parents or
legal guardian of a minor, whereby authorization is given to a certain individual(s) to
seek and obtain medical treatment, including dental treatment, for the minor in the event
of an emergency. This form should be used by parents or legal guardians who want to
grant such authorization to certain individual(s).
                                            Authorization for Minor’s Medical Treatment


  AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT

I/WE THE PARENTS/LEGAL GUARDIAN OF THE MINOR CHILD
________________________, HEREBY PROVIDE OUR AUTHORIZATION AND
CONSENT TO MEDICAL TREATMENT FOR OUR/THE MINOR CHILD.

Child’s Full Legal Name:

Date of Birth:                              Social Security No:

Address:                                           Telephone:

Mother’s Full Legal Name:

Address:                                           Telephone:

Father’s Full Legal Name:

Address:                                           Telephone:

Legal Guardian Full Legal Name:

Address:                                           Telephone:


Family Physician Information:

Name of Family Physician:

Address:                                           Telephone:

Child’s Known Allergies:

Current Medications Child Takes:                            Dosage:

Medical Insurance? If yes please specify:

Medical Insurance Policy No:

Other Medical Conditions:
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Family Dentist Information:


Dentist Name:                                         Address:

Telephone:

Dental Insurance? If so please Specify:

Policy No:


                    AUTHORIZATION FOR MEDICAL TREATMENT


I/WE DO HEREBY SOLEMNLY SWEAR that I/we are the natural parent(s)/legal guardian of
the minor child ____________________, born on the ____ day of ___________, 2_____.

I/WE     HEREBY        GRANT        OUR       AUTHORIZATION          AND     CONSENT        to
_______________________ (enter name of person to whom authorization is being given to for
medical treatment) to obtain any and all necessary medical treatment for the said minor child.
This authorization and consent shall include, but not be limited to:

       (i)     obtaining emergency medical treatment for the said child, including but not
               limited to, X-rays, anaesthetic, blood transfusion, medication and surgery should
               the said child so require, provided such medical or emergency medical treatment
               is administered and performed by a physician properly licensed in accordance
               with the laws of the governing jurisdiction;

       (ii)    the administration of any necessary first aid treatment for any injury or illness;

       (iii)   obtaining any and all necessary or emergency dental treatment for the said child
               should the said child so require, provided such dental treatment is administered
               and performed by a dentist properly licensed in accordance with the laws of the
               governing jurisdiction; and

       (iv)    the transporting of the said child by any emergency personnel to any required
               medical or dental facility.


I/WE HEREBY GRANT TO _______________________ ALL OF MY/OUR MEDICAL
DECISION MAKING POWERS IN RESPECT TO THE SAID CHILD IN MY/OUR
ABSENCE.
                                        4


THIS AUTHORIZATION AND CONSENT shall take effect on the ___ day of __________,
2____ and shall expire on the _____ day of _____________, 2______.

SIGNED, SEALD AND DELIVERED         )
in the presence of:                 )
                                    )
                                    )
Notary Public                       )       Mother/Legal Guardian
                                    )
                                    )
Notary Public                       )       Father/Legal Guardian
                                                                     5


				
DOCUMENT INFO
Description: This Authorization for a Minor’s Medical Treatment is executed by the natural parents or legal guardian of a minor, whereby authorization is given to a certain individual(s) to seek and obtain medical treatment, including dental treatment, for the minor in the event of an emergency. This form should be used by parents or legal guardians who want to grant such authorization to certain individual(s).