Cnyfamilycare - Authorization for Medical Treatment of Minors

AUTHORIZATION FOR MEDICAL TREATMENT OF MINORS
Parent/Guardian Name:*
You are the...*
Child's Name:*
Child is...*
Child's DOB*

MonthDayYear
Date
(Name of Person/ Agency who will bring child to the doctor in your absence)*
Child's Name:*
Start date of Consent*

MonthDayYear
Date
End date of Consent*

MonthDayYear
Date
In presenting my son/daughter for diagnosis and treatment at CNY Family care

Parent/Guardian Name: __{parentguardianName} ({youAre})__ for my child __{childsName} ({childIs})__ with a date of birth of __{childsDOB}__, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment, by authorized members of CNY Family Care staff or their designees, as may in their professional judgement be necessary.

I hereby acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my child's condition. I have read this and certify that I understand its contents.

We/I hereby give consent to __{nameOf}__
who will be caring for our (my child) __{childsName}__

This consent shall remain in effect from __{startDate}__ until __{endDate}__, unless sooner revoked in writing and delivered to said physician or dentist or said persons entrusted with the care of said minor child.

We/I acknowledge that we are (I am as the parent/guardian) responsible for all reasonable charges in connection with the care and treatment rendered to my child during this period.
Parent/Guardian Name:*
Telephone No.*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Physician:
Child's allergies, if any:
Special needs, if any:
Name of Insurance Center*
Insurance ID#*
Signature*

Clear
Date

MonthDayYear
Date
Witness Name
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR MEDICAL TREATMENT OF MINORS