Authorization For Treatment Consent Form

Authorization For Treatment Consent Form

This From is Encrypted & HIPAA Compliant
Parents: Use this form to give authorization to authorization for someone else to bring your child for visits.
Date*

MonthDayYear
Date
I, Parent or Legal Guardian's Name * give permission to (person who will be bring the child to the appointment) * to seek medical treatment and make any medical decisions as necessary for my child.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent or Legal Guardian Signature*

Clear
Should be Empty: