Authorization to Treat Minor

Today's Date:

Child's Name:

Child's Date of Birth:

Name of person will accompany the above named child and make medical decisions in the event that a parent/guardian cannot be reached:

Relationship of above named person to parent/legal guardian:

Phone number where Parent/Legal Guardian may reach in case of emergency:

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.

Parent/Legal Guardian's Signature:

Please Note: This form is only valid on the date listed above and MAY NOT be used for well child visits.
A parent or guardian MUST be present for well child visits.

Your information will be encrypted.