AUTHORIZATION TO TREAT A MINOR

This consent shall remain effective until __________, 19______

I(we) the undersigned parent, parents or legal guardian of ________________________________________________ a minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical 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 Medicine Practice Act , of a Dentist licensed under the provisions of the Dental Practice Act, and on 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 judgement may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.

List any
restrictions:___________________________________________________________________________ ________________

_________________________________________________________________________________________ ___________________

_________________________________________________________________________________________ ___________________

Signature of Father, Mother
or Legal Guardian:________________________________________________________________Date:_____________

Address:____________________________________ City:__________________________ State:______ Zip:_________

Birth Date:_______________________________________________________________________________________ __

Last Tetanus Toxoid Booster: _________________________________________________________________________

Allergies to Drugs or Foods: _________________________________________________________________________

Any Special Medications
Or Pertinent Information:___________________________________________________________________________

_________________________________________________________________________________________ ________

Telephones Where Parents May Be Reached

Father:____________________________________ Home:_________________________ Work:____________________

Mother:___________________________________ Home:_________________________ Work:____________________

Family Physician:__________________________________________________________________________________ __

Address:____________________________________ City:__________________________ State:______ Zip:_________

Insurance Company: ___________________________________________________Policy No._____________________