marketingbysos.com - Consent to Treat Form

CONSENT TO TREAT MINOR CHILDREN

(Please fill out all information)
I, (Parent/Guardian Name) , parent or legal guardian of (Patient’s Name) , born on the Type a label day of Date , do hereby consent and allow (Authorized Adult) to handle any type of medical care for my child including but not limited to the administration of anesthesia determined by a physician, surgery, and any other care recommended or deemed as necessary for the welfare of my child.

This authorization is effective from Date to Date .
Signature of Parent/Legal Guardian

Clear
Witness Signature

Clear
Witness Name
This consent form should be taken with the child to the hospital/physician’s office when the child is taken for treatment.

This additional information will assist in treatment if it can be furnished with the consent but is not required.
Family Address:
Telephone:
Father:
Please enter a valid phone number.
Home:
Please enter a valid phone number.
Work:
Please enter a valid phone number.
Father:
Please enter a valid phone number.
Home:
Please enter a valid phone number.
Work:
Please enter a valid phone number.
Child’s Birthdate:

MonthDayYear
Date
Allergies to drugs or foods:
Should be Empty:

CONSENT TO TREAT MINOR CHILDREN