Medical Treatment Authorization and Consent
I, {{parent_full_name ? parent_full_name : '__________________________'}} and {{sub_parent_full_name ? sub_parent_full_name : '__________________________'}} the {{parent ? parent : '[parent/legal guardian]'}} and {{sub_parent ? sub_parent : '[parent/legal guardian]'}} of {{child_full_name ? child_full_name : '__________________________'}} authorize {{caregiver_full_name ? caregiver_full_name : '__________________________'}} to seek, obtain and consent to
{{consents}},
for {{child_full_name ? child_full_name : '__________________________'}} as deemed necessary by a licensed medical or healthcare professional. This authorization is for the time period when my child is in the care of {{caregiver_full_name ? caregiver_full_name : '__________________________'}} and is effective {{computedBeginningConsent ? computedBeginningConsent : '__________'}} until {{computedEndingConsent ? computedEndingConsent : '__________'}}.
Child’s Information:
Child’s Full Name: {{child_full_name ? child_full_name : '__________________________'}}
Address:
{{computedParentAddress ? computedParentAddress : '__________________________'}}
{{computedSubParentAddress ? computedSubParentAddress : '__________________________'}}
{{computedChildAddress ? computedChildAddress : '__________________________'}}
Date of Birth: {{computedChildDOB ? computedChildDOB : '__________________________'}}
Age: {{child_age ? child_age : '__________________________'}}
Sex: {{child_gender ? child_gender : '__________________________'}}
Parent/Guardian’s Information:
Parent’sLegal Guardian’s Name 1: {{parent_full_name ? parent_full_name : '__________________________'}}
Address: {{computedParentAddress ? computedParentAddress : '__________________________'}}
Phone Number: {{parent_phone ? parent_phone : '__________________________'}}
Parent’sLegal Guardian’s Name 2: {{sub_parent_full_name ? sub_parent_full_name : '__________________________'}}
Address: {{computedSubParentAddress ? computedSubParentAddress : '__________________________'}}
Phone Number: {{sub_parent_phone ? sub_parent_phone : '__________________________'}}
Child’s Health Information:
Health Conditions: {{child_health_conditions ? child_health_conditions : '__________________________'}}
Allergies: {{allergies ? allergies : '__________________________'}}
Prescription Medications: {{prescriptions ? prescriptions : '__________________________'}}
Date of Last Tetanus Injection/Booster: {{tetanus ? tetanus : '__________________________'}}
Child’s Medical Care and Insurance Information:
Physician/Pediatrician: {{physician ? physician : '__________________________'}}
Dentist/Orthodontist: {{dentist ? dentist : '__________________________'}}
Preferred Medical Facility: {{preferred_medical ? preferred_medical : '__________________________'}}
Insurance Company: {{insurance ? insurance : '__________________________'}}
Policy/Group Number: {{policy ? policy : '__________________________'}}
SIGNATURE OF PARENT/GUARDIAN:
Parent’sLegal Guardian’s Signature __________________________ Date __________________________
Print Name __________________________
Parent’sLegal Guardian’s Signature __________________________ Date __________________________
Print Name __________________________
WITNESSES:
|
_____________________________________
First Witness Signature
_____________________________________
First Witness Printed Name
_____________________________________
Date
_____________________________________
First Witness Address
_____________________________________
First Witness City, State, Zip
|
_____________________________________
Second Witness Signature
_____________________________________
Second Witness Printed Name
_____________________________________
Date
_____________________________________
Second Witness Address
_____________________________________
Second Witness City, State, Zip
|
NOTARY ACKNOWLEDGMENT:
State of _______________________________
County of ____________________________
On this the ________ day of __________________, 20__, before me, the undersigned, a notary public in and for said County and State, personally appeared __________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
___________________________________
(Signature of Notary)
Notary Public for the State of _____________________
Date of Expiration: _____________________
(Seal)
