Authorization for Minor's Medical Treatment

Authorization for Minor's Medical Treatment

Use this form to give someone authority to authorize medical care for your child.  From sports games to dance lessons, this form will help avoid delays or roadblocks in getting medical care to your child. 

You can save and edit the form before you buy--just create a Nolo.com account. It's easy, free, and there's no obligation to buy anything. If you purchase the form, you'll be able to print, send, or download it.

See below the form for a full product description.

Alternate Selection: [number of parents signing document]
Label Contract Text
one

I, , am the parent or legal guardian of, and have legal custody of, . If I cannot be reached to consent to medical or dental care for my child, , I authorize  to give consent to such care in my place.

This authorization includes permission to consent to medical and dental care for my child, including but not limited to medical examinations, X-rays, tests, anesthesia, surgical operations, hospital care, or other treatments that in the opinion of are needed or useful for my child. Such medical treatment shall be provided only upon the advice of and supervised by a physician, surgeon, dentist, or other medical practitioner licensed to practice in the United States.

two

We,  and , are the parents or legal guardians of, and have legal custody of, .  If neither of us can be reached to give consent to medical or dental care for our child, we authorize  to give consent to such care in our place.

This authorization includes permission to consent to medical and dental care for our child, including but not limited to medical examinations, X-rays, tests, anesthesia, surgical operations, hospital care, or other treatments that in the opinion of  are needed or useful for our child. Such medical treatment shall be provided only upon the advice of and supervised by a physician, surgeon, dentist, or other medical practitioner licensed to practice in the United States.

Child's Information

Name: 
Birthdate: 
Age: 
Grade in school: 

Doctor: 
Address: 
Phone: 

Medical insurer/health plan: 
Policy no.: 

Allergies to medications: 
Other allergies: 
Medications the child is currently taking: 

Other important medical information:

Dentist: 
Address: 
Phone: 

Dental insurer/plan:    
Policy no.: 

Parent Contact Information

Alternate Selection: [parent contact information]
Label Contract Text
one parent or guardian

Name: 
Address:
Phone: 
Email: 

Additional contact information: 

two parents or guardians

Name: 
Address: 
Phone: 
Email: 

Additional contact information: 

Name: 
Address: 
Phone: 
Email: 

Additional contact information: 

Emergency Contact

Name: 
Address: 
Phone: 
Email: 

Additional contact information: 

Keep Together
Alternate Selection: [number of parents signing document]
Label Contract Text
one

Signature

Signature: _______________________________
Date: ______________________________

two

Signatures

Signature: _______________________________
Date: ______________________________

Signature: _______________________________
Date: ______________________________

 

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1-Year Subscription

Price: $29.99

Use this form to let an adult authorize medical or dental care for your child. This is helpful when another adult is caring for your child while you are away, or if your child is participating in sports or other organized activity outside of your supervision.

If your child is participating in an activity such as a basketball league or dance lessons, the sponsoring organization will most likely give you its own medical authorization to fill out. If it doesn’t, complete this simple form.

Important to Know

  • Without authorization, supervisors may face delays -- or even brick walls -- while trying to help your child get medical attention following an accident.
  • This form may be witnessed or acknowledged by a notary public. Practically speaking, a notarized form is likely to be more readily accepted by others.

Additional Technical Support FAQs

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Windows

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  • Adobe Reader 9 or higher
  • JavaScript must be enabled

Macintosh OS X

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  • Adobe Reader 9 or higher, or Preview
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