Consent to Treatment of a Minor when parents/guardians are temporarily unavailable
This form gives consent from parent(s) or guardian(s) of a minor child for treatment including, but not limited to hospitalization admission, anesthetic, diagnostic imaging or other treatment by a physician. It is understood that this consent is given in advance to any specific diagnosis or treatment being required, but is given to provide authority to the physician to diagnose and treat the minor in the parent(s)/guardian(s) absence.
Legal Name of Listed Minor
*
First Name
Middle Name
Last Name
Minor Date of Birth
*
-
Month
-
Day
Year
Date
Name of Authorized Individual for Consent to Treat
*
First Name
Middle Name
Last Name
Please list any medical concerns, learning disabilities, or other pertinent information about the treatment of the minor (else mark as N/A)
*
Please list any known allergies (if none, please mark as such):
*
Please List Health Insurance Plan (Insurer Name, ID and Group Number)
*
Primary Emergency Contact
*
First Name
Last Name
Primary Emergency Contact Phone Number
*
-
Area Code
Phone Number
Secondary Emergency Contact
*
First Name
Last Name
Secondary Emergency Contact Phone Number
*
-
Area Code
Phone Number
Back
Next
Parent or Guardian's Name
*
First Name
Last Name
Relationship to Minor
*
Father
Mother
Step-Parent
Legal Guardian
Other legal representitive
Work Phone
*
-
Area Code
Phone Number
Mobile/Home Phone
*
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature of Parent or Guardian
*
Parent or Guardian's Name
First Name
Last Name
Relationship to Minor
Father
Mother
Step-Parent
Legal Guardian
Other legal representitive
Work Phone
-
Area Code
Phone Number
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature of Parent or Guardian
Submit
Should be Empty: