Appendix D: authorization for consent to medical treatment of minor.

• Pages: #2003

AUTHORIZATION FOR CONSENT TO MEDICAL TREATMENT OF MINOR

I, -- being the parent entitled to the legal and physical custody of my minor child --, born --, do hereby authorize --, into whose care the child has been entrusted, to consent to any X-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care to be rendered to said child under the supervision and upon the advice of a physician or other medical care provider licensed to practice medicine in any state in the United States. I further authorize --, to consent to any X-ray, examination, dental, or surgical diagnosis or treatment and hospital care to be rendered to said minor child by a dentist licensed to practice dentistry in any state in the United States.

This shall be valid from -- to --. Executed this -- day of --, 20 --, at --.

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Signature of Principal

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

State of --) ) SS. County of --) On -- before me, --, personally (Date) (Notary) appeared -- Signer(s) Personally known to me - OR - proved to me on the basis of satisfactory evidence to be...