Parent/Guardian Delegation Form authorizing the care of a minor

Parent/Guardian Delegation Form authorizing the care of a minor
Patient Name*

First NameLast Name
I, hereby, give authorization to the following person to approve and consent to any treatment of the above named minor that may be needed during his/her/their office visit
Name of person to who authority delegated

First NameLast Name
Relationship to patient
Parents/Guardians: please make arrangements to ensure that all copayments and non- covered services are paid at the time services are rendered
Email
example@example.com
Signature
Should be Empty:

I, hereby, give authorization to the following person to approve and consent to any treatment of the above named minor that may be needed during his/her/their office visit