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Texas Guardianship Form 2

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Texas Guardianship Form 2
AUTHORIZATION FOR TEMPORARY GUARDIANSHIP OF MINOR
Child(ren)
Full Legal Name:
____________________________________________________________________________
Date of Birth: _______________________ Age: ___________ Gender: ___________
Allergies to Medications:
____________________________________________________________________________
Allergies (Other):
____________________________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
____________________________________________________________________________
Full Legal Name:
____________________________________________________________________________
Date of Birth: _______________________ Age: ___________ Gender: ___________
Allergies to Medications:
____________________________________________________________________________
Allergies (Other):
____________________________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
____________________________________________________________________________
Doctor’s Information
Doctor’s Name:
____________________________________________________________________________
Doctor’s Address:
____________________________________________________________________________
Doctor’s Office Phone: ____________________
Doctor’s Emergency Phone: __________________
Medical Insurer/Health Plan: __________________________ Policy #: ____________________
Note any other significant medical information:
_____________________________________________________________________________
_____________________________________________________________________________
Texas Guardianship Form 2
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