Authorization for Minor's Medical Treatment

AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT

Child

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

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, please note the conditions for which the child is currently receiving treatment:
_________________________________________________________________________________
Note any other significant medical information:
_________________________________________________________________________________
_________________________________________________________________________________

Dentist's Information
Dentist's Name: ____________________________________________________________________
Dentist's Address: __________________________________________________________________
Dentist's Office Phone: ____________________ Dentist's Emergency Phone: __________________
Dentist's 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 "Supervising Adult") 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 #1's Signature

______________________________________
Parent #2's 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: __________________