I, *, parent or guardian of *, a minor, do hereby authorize the following name(s); (example: name of friend, grandparent, aunt, uncle, neighbor, etc.):
As my agent(s) to consent to any medical evaluation and/or treatment, surgery evaluation and/or treatment, diagnosis or care, which is deemed advisable by and is to be rendered under, the general or special supervision of a licensed physician or physician assistant. This authorization includes hospital admission if such is deemed necessary by the physician. It is understood that this authorization is given to provide authority and power on the part of my aforesaid agent(s) to give specific consent to any and all such evaluation, diagnosis, office treatment, in-office minor diagnostic procedures, prescriptions, photos or surgical treatment(s). This authorization also grants to my agent(s) the power to sign for release of information to any third party payers who may be responsible for part or all of the cost of the services provided. This authorization shall remain effective from * to *, unless sooner revoked in writing delivered to said agent(s).