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Free Authorization for Minor’s Medical Treatment Form

Forms in Medical

Download and use this form if you want to give the Custody of a Minor child’s Medical decisions to someone who you trust.

Authorization for Minor’s Medical Treatment

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Text Version of this Form

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Authorization for Minor’s Medical Treatment

Child

Name: ______________________________

Birthdate: ________________ Age: ________ Grade in school: ____________

Doctor (or HMO): ______________________________

Address: ______________________

______________________

Phone: ____________________

Medical insurer/health plan: ____________________ Policy no.: _________________

Allergies (medications): ______________________________

Allergies (other): ____________________________________

Conditions for which child is currently receiving treatment:

__________________________________________________________________

Other important medical information:

__________________________________________________________________

Dentist: ______________________________

Address: ______________________

______________________

Phone: ____________________

Dental insurer/plan: ___________________________ Policy no.: _________________

Parents (or Legal Guardians)

Parent 1

Name: ____________________

Address: ______________________

______________________

Home phone: ____________________ Work phone: ____________________

Cell phone or pager: ____________________ Email: ____________________

Additional Contact Information: ___________________________

Parent 2

© 2007 Nolo Authorization for Minor’s Medical Treatment Page 1

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Name: ____________________

Address: ______________________

______________________

Home phone: ____________________ Work phone: ____________________

Cell phone or pager: ____________________ Email: ____________________

Additional Contact Information: ___________________________

Other Adult to Notify in Case Parent(s) Cannot Be Reached

Name: ____________________

Address: ______________________

______________________

Home phone: ____________________ Work phone: ____________________

Cell phone or pager: ____________________ Email: ____________________

Additional Contact Information: ___________________________

Authorization and Consent of Parent(s) or Legal Guardian(s)

I affirm that I have legal custody of the minor child indicated above. I give my
authorization and consent for __________________________ [name of supervising
adult], who is a(n) _____________ [title and name of organization, if appropriate], to
authorize necessary medical or dental care for my child. Such medical treatment shall be
provided upon the advice of and supervised by any physician, surgeon, dentist, or other
medical practitioner licensed to practice in the United States.

Parent 1’s signature: ___________________________________ Date: ______________

Parent 2’s signature: ___________________________________ Date: ______________

Certificate of Acknowledgment of Notary Public

State of _______________________________ )

) ss

County of _____________________________ )

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On _____________________, before me, ______________________________, a notary
public in and for said state, personally appeared ___________________
________________________, personally known to me (or proved to me on the basis of
satisfactory evidence) to be the person whose name is subscribed to the within
instrument, and acknowledged to me that he or she executed the same in his or her
authorized capacity and that by his or her signature on the instrument, the person, or the
entity upon behalf of which the person acted, executed the instrument.

WITNESS my hand and official seal.

_____________________________________

Notary Public for the State of ______________

My commission expires __________________

[NOTARY SEAL]

© 2007 Nolo Authorization for Minor’s Medical Treatment Page 3

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