Authorization To Treat A Minor

Authorization to Treat A Minor
I, the undersigned, hereby authorize providers at St. Anthony Physician Clinics to provide medical treatment and/or surgical treatment to my child. I further authorize the following people acting on my behalf to consent to such medical and/or surgical treatment as St. Anthony Physician Clinics’ medical providers may deem medically necessary or advisable for my child.
Adults Name

First NameLast Name
Relationship to Child
Adults Name

First NameLast Name
Relationship to Child
Adults Name

First NameLast Name
Relationship to Child
Adults Name

First NameLast Name
Relationship to Child
This authorization shall remain in effect until:

MonthDayYear
Date
Child's Information
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Signature/Authorization
Parent/Legal Guardian's Name

First NameLast Name
Relationship
If other, please specify relationship
Parent/Legal Guardian Signature
St. Anthony Clinic Employee Signature
Should be Empty:

Authorization to Treat A Minor