Medical Consent Form

Medical consent Form
Date

MonthDayYear
Date
Minor's Name:

First NameLast Name
DOB

MonthDayYear
the above referenced minor is in the custody of enter agency name This is to certify that the One Way farm is a licensed Group Home Agency providing care for a child placed in the custody of fill in the blank and with the above Medical consent is authorized to sign for necessary care and treatment for the child named on this consent.
Children's Services authorized Guardian
Date signed

MonthDayYear
Date
Should be Empty:

Medical consent Form