Health Release: *
Parent/guardian authorization to an adult person to consent to medical or dental treatment of minor indicated above. I am the parent and/or guardian of the minor listed above. I hereby authorize the adult diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practices Act or a dentist licensed under the provisions of the Dental Practices Act and the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that reasonable effort shall me made to contact the undersigned prior to rendering treatment to the patient; but that none of the above treatment shall be withheld in the event the undersigned cannot be contacted. This authorization shall be in effect until June 30, 2018.
(By selecting the checkbox below you agree to the terms and conditions above, and give authorized permission.)