Authorization for Non-Parent Consent for Treatment of Minor Child

Please correct the errors described below.

Please fill out this form if your child will be coming for a visit, treatment, or procedure, accompanied by someone other than a parent or legal guardian. This agreement will stay in effect for one year from the date of signature below unless revoked in writing by a parent or legal guardian.

I approve the above-named person to seek health care for my minor child listed above. I know that I am financially responsible for all health care fees incurred by my child during these visits.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

For Foster Care:

I approve the above-named person to seek health care for the minor child listed above. Financial duty for health care fees owed during these visits is outlined in the foster care records.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.