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Medical Treatment Authorization and Consent Form


Medical Treatment Authorization and Consent Form
Medical Treatment Authorization and Consent Form
MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM
The following form is designed for those situations where minors are unaccompanied by either parents or
legal guardians. This “Medical Treatment Authorization and Consent Form” gives authority to a
designated adult to arrange for medical care for a minor in the event of an emergency. This is extremely
important, in that, medical care can not be provided to a minor without approval by the parents or legal
guardians, unless there is written consent authorizing an agent to give approval.
Minors Full Name
Minors Address
City, State, Zip Code
Minors Age
The undersigned do hereby authorize Christopher Tate/Alison Sigethy or such substitute as he/she may
designate as agent for the Undersigned to consent to any X-Ray, anesthetic, medical, dental, or surgical
diagnosis or treatment and hospital care for the above named minor which is deemed advisable by and to
be rendered under the general or special supervision of any physician and/or surgeon, licensed under the
Provision of Medicine Practice Act or of any dentist licensed under the Dental Practice Act, whether such
diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere.
Parent or Guardian Signature Date
Parent or Guardian (please print)
Address Parent or Guardian
Home and Work Phones of Parent or Guardian
Witness
Insurer Account Number
Family Physician
Family Physician’s Full Address
Medical Treatment Authorization and Consent Form