Consent for Care

Consent for Care
Consent for Care
I   Name*  of   City*,  State*   do hereby state that I am the parent/legal guardian of:   Child's Full Name*   DOB:   *   who resides with me at   *   .

I authorize:
Name*   Relationship:   *
Name   Relationship:
Name   Relationship:
Name   Relationship:
to act on my behalf in authorizing medical care for the above named minor.

*In no event shall this delegation of parental rights be effective for more than one year from the date listed below.
Signature of parent/guardian*
Date*

MonthDayYear
I understand that this form will be placed in my child's medical record and will be used for the sole purpose of treating my child at the above named clinic.

Send a list of any medications your child is currently taking with the individual that will be bringing them.
Should be Empty: