AUTHORIZATION TO TREAT MINOR

AUTHORIZATION TO TREAT MINOR
Name of Patient*

First NameLast Name
Patient's Date of Birth*
I, give permission for medical treatment to the minor listed above. If for any reason, the course of treatment changes or if there is a request by the minor to treat something other than the course of treatment for an ongoing condition, I agree to be contacted by the provider for discussion.
Name of parent or guadian*

First NameLast Name
Signature of parent or guardian:*

Clear
Relationship to patient:*
Phone Number*

Area CodePhone Number
Date*
Should be Empty: