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: __________________________