Authorization for Medical Treatment for Minors

If your child needs medical or dental attention, you as a parent must give permission. It's the law. What about the times you can't be reached for permission? In a serious case, a physician can act right away to treat your child. In other cases, a hospital will authorize treatment, but only after making an effort to contact you first, and that can mean unnecessary anxious moments for your child while someone tries to contact you. For those times when it will be hard to contact you, you can give permission to other adults. They can then act for you in permitting medical or dental care for your child when you're not available. This is a legal document. With it, you may appoint other adults to act for you.

Complete this form and sign in front of a witness. DO NOT MAIL THIS FORM. It should be kept by the responsible adult.
 
 
 
NAME OF MINOR
BIRTHDATE
IDENTIFY ALLERGIES OR SPECIAL CONDITIONS

I/We, being the parent(s) or legal guardian(s) of the above named minor(s), do hereby appoint
 
Name: Address:
 
 
Phone:
 
Second Person (optional): Address:
 
 
Phone:

 

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

This document shall be presented to a physician, dentist, or appropriate hospital representative at such time as unexpected medical, dental, surgical care or hospitalization as may be required.
 
Parent/Guardian
Parent/Guardian
SIGNATURE
 
SIGNATURE
ADDRESS
 
DATE ADDRESS DATE
Witness
Witness
SIGNATURE
 
SIGNATURE
ADDRESS
 
DATE ADDRESS DATE
Hospitalization Coverage for above-named minor
INSURANCE COMPANY OR GOVERNMENT PROGRAM
 
ID OR CONTRACT NUMBER
Family Physicians
DOCTOR'S NAME AND PHONE NUMBER DENTIST'S NAME AND PHONE NUMBER