Medical Treatment Authorization and Consent Form

MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM

The following form is designed for those situations where minors are unaccompanied by either parents or

legal guardians. This “Medical Treatment Authorization and Consent Form” gives authority to a

designated adult to arrange for medical care for a minor in the event of an emergency. This is extremely

important, in that, medical care can not be provided to a minor without approval by the parents or legal

guardians, unless there is written consent authorizing an agent to give approval.

Minor’s Full Name

Minor’s Address

City, State, Zip Code

Minor’s Age

The undersigned do hereby authorize Christopher Tate/Alison Sigethy or such substitute as he/she may

designate as agent for the Undersigned to consent to any X-Ray, anesthetic, medical, dental, or surgical

diagnosis or treatment and hospital care for the above named minor which is deemed advisable by and to

be rendered under the general or special supervision of any physician and/or surgeon, licensed under the

Provision of Medicine Practice Act or of any dentist licensed under the Dental Practice Act, whether such

diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere.

Parent or Guardian Signature Date

Parent or Guardian (please print)

Address Parent or Guardian

Home and Work Phones of Parent or Guardian

Witness

Insurer Account Number

Family Physician

Family Physician’s Full Address

Fillable Printable Medical Treatment Authorization and Consent Form