NOTE: Either PART I or PART II must be completed.
unsuccessfully, I hereby give my consent for:
1) The administration of any treatment deemed necessary by
or in the event the designated practitioner is not available, by another licensed physician or dentist; and The transfer of the child to
This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
In the event of an emergency, I do not give my consent for my child to be treated under any conditions without my being present.
I hereby absolve Greater Augusta Apostolic Church of any and all responsibility for my child's well being.