Authorization to Consent to Treatment of a Minor

Student Information
Name of Minor*

First NameMiddle NameLast Name
Full Name
Date of Birth*

MonthDayYear
Minor's Birthdate
Student is over 18 and therefore does not need this form.
18th Birthday

MonthDayYear
Minor's Birthdate
Age

Authorization to Consent to Treatment of a Minor
I/We, the undersigned parent(s)/guardian(s) of {fullName}, a minor, do hereby authorize University of California, Berkeley Health Services or attending medical personnel as agent(s) for the undersigned to consent to any X-ray examinations, anesthetic, medical or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician and/or surgeon licensed under the provisions of the Medical Practices Act, California Business and Professions Code §2000 et. seq.; or any X-ray examination, anesthetic, dental or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any dentist licensed under the provisions of the Dental Practices Act, California Business and Professions Code §1600 et. seq..

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which aforementioned physician or dentist, in the exercise of his/her best judgment, may deem advisable. This authorization is given pursuant to the provisions of California Family Code §6910..

I/We hereby authorize any hospital, which has provided treatment to the above-named minor pursuant to the provisions of California Family Code §6910, to surrender physical custody of such minor to my/our above-named agent(s) upon the completion of treatment. This authorization is given pursuant to California Health and Safety Code §1283..

These authorizations shall remain effective until the minor’s 18th birthday on {studentBday}, unless sooner revoked in writing delivered to said agent(s).
Signed: *

Clear
Date of Signature:

MonthDayYear
You will be able to download a PDF copy of the signed agreement upon submission of this form, however if you would like a copy of the signed agreement emailed to you, please provide your email here:
example@example.com

Emergency Information
In case of emergencies, notify:
Emergency Contact Name: *
Address: *

Phone Number(s): *

	Phone	Phone Number
1.
2.
3.

If different than above, complete:
Contact Name:
Address:

Phone Number(s):

	Phone	Phone Number
1.
2.
3.

Contact Name
Address

Phone Number(s):

	Phone	Phone Number
1.
2.
3.

Minor's Physician
Physician's Name:
Address:
Phone Number:
Please enter a valid phone number.
Name of Medical Insurance Provider:
Policy #
Expiration Date:

MonthDayYear
Attach a copy of your medical card:

Cancelof
If your child has a medical problem or is taking medication that would be important for us to be aware of, please indicate here:
Should be Empty:

Student Information

Authorization to Consent to Treatment of a Minor

Emergency Information

In case of emergencies, notify:

If different than above, complete:

Minor's Physician