Consent to Treat Patient - Without Legal Guardian or Authorized Agent Present
For those occasions when you may not be with the patient/Ward for whom you are the only appointed Guardian of the person or the designated Power of Attorney under a Durable Power of Attorney for health care previously executed by the patient, please list those individuals, if any who may authorize consent in your absence.
Patient Name:
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Patient Date of Birth:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Name:
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Please list the person who may authorize consent in the absence of the guardian.
Relationship to Patient:
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Name:
Please complete if there is more than one person that has consent when guardian is absent.
Relationship to Patient:
LIMITATIONS
Identify any specific limitations on the kinds of medical/dental services for which this authorization is given.
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(If none, state "none".)
Check the square below if you wish to give consent for the patient/ward to receive medical care without an accompanying adult.
I consent.
This is effective:
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indefinitely, until revoked by written communication.
for a specific date only. (Enter below.)
AUTHORIZATION:
I, name stated above, request and authorize Muskingum Valley Health Centers and its personnel to deliver routine medical/dental care to my patient/ward listed above as may be deemed necessary or advisable in the diagnosis and treatment of the patient/ward. I am also aware that the patient/ward is responsible for payment of the patient portion at the time of service. I have the legal right to preauthorize Muskingum Valley Health Centers and its personnel to deliver routine medical/dental treatment and services to the patient/ward. Routine medical/dental care and interventions may include, but are not limited to: medical evaluation, dental health, physical exam, routine immunizations, injections, x-rays, lab work (examples: throat or nasal swabs, blood draws, urine catheterizations, wart treatment with liquidnitrogen, minor burns, minor suturing of lacerations). I have read, understand, and give my consent as stipulated above. My signature means that I have read this form and/or have had it read to me and explained in the language that I can understand. If I am the guardian of the person a copy of my letters of guardianship are attached.
Authorized Agent or Legal Guardian Name:
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Relationship:
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Authorized Agent or Legal Guardian Signature:
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Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Should be Empty: