Authorization to Consent to Medical Treatment of Child

Park Valley Behavioral Health Care
Authorization to Consent to Medical Treatment of Child

Please submit a new form for each child and/or each agent
I, full name* make oath and say that I am the parent and/or lawful guardian of the child listed below and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
I hereby authorize and appoint the following person as my agent.*

First NameLast Name
Address of Agent *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My agent may consent to my child's medical examination or treatment.

Such treatment may include, but is not limited to the following:
1. Accompany to medical and/or counseling appointments
2. Transportantion by ambulance
3. Examination
4. Diagnoses
5. Hospitalization
6. Medication
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Park Valley Behavioral Health Care