Authorization for Minors Medical Treatment by ReadyBuiltForms

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This form allows a custodial parent to authorize another adult to do any acts which may be necessary or proper to provide for the health care of the minor child. Best Deal! Get this form and 5 more in a Family Package for Only $39.95

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									AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT (By Supervising Adult)

Child Full Legal Name: ___________________________________________________________________ Date of Birth: __________ Age: __________ Male/Female: _ -______ Doctor’s Information Doctor’s Name: ___________________________________________________________________ Doctor’s Address: ___________________________________________________________________ Doctor’s Office Phone: __________Doctor’s Emergency Phone: _______________ Medical Insurer/Health Plan: ___________________ Policy #:________________ Allergies to Medications: ___________________________________________________________________ Allergies (Other): ___________________________________________________________________ If applicable, identify any medical conditions for which the child is currently receiving treatment: ___________________________________________________________________ Other significant medical information: ___________________________________________________________________ ___________________________________________________________________ Dentist’s Information Dentist’s Name: ____________________________________________________________________ Dentist’s Address: ____________________________________________________________________ Dentist’s Phone: ____________________ Dentist’s Emergency Phone: __________ Dental Insurer/Health Plan: _________________________ Policy #:___________ Parent(s)/Legal Guardian(s): Parent Name: ________________________________________________________________________ Address: ________________________________________________________________________ Home phone: __________________________
								
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