Designation Form
This form allows you to designate another person(s) provide consent for treatment if you are unable to accompany your child to London Women's Care.
Parent or Legal Guardian Information
Please provide your name and date of birth, as the parent or legal guardian of the child.
Name of Parent or Legal Guardian
*
First Name
Last Name
Parent or Legal Guardian Date of Birth
*
-
Month
-
Day
Year
Date
Child (Patient) Information
Please provide the name and date of birth of the minor patient.
Name of Child
*
First Name
Last Name
Child Date of Birth
*
-
Month
-
Day
Year
Date
Designee Information
Please provide the following information for the person(s) that you authorize to provide consent of treatment for your child. The person(s) listed must be at least 18 years of age or older. I understand that this designation may include medication and treatment, but does not include consent for vaccines.
Designee #1 Name
*
First Name
Last Name
Designee #1 Date of Birth (Must be at least 18 years of age)
*
-
Month
-
Day
Year
Date
Designee #1 Driver's License Number
*
Designee #2 Name
First Name
Last Name
Designee #2 Date of Birth (Must be at least 18 years of age)
-
Month
-
Day
Year
Date
Designee #2 Driver's License Number
Designee #3 Name
First Name
Last Name
Designee #3 Date of Birth (Must be at least 18 years of age)
-
Month
-
Day
Year
Date
Designee #3 Driver's License Number
Designee #4 Name
First Name
Last Name
Designee #4 Date of Birth (Must be at least 18 years of age)
-
Month
-
Day
Year
Date
Designee #4 Driver's License Number
Authorization & Signature
As the parent or legal guardian listed above, I affirm that I am unable to accompany my child to London Women's Care. Therefore, I give permission to the Designee(s) listed above to provide consent of treatment for my child, which may include medication and treatment, but does not include consent for vaccines.
Signature
Clear
Submit
Should be Empty: