THIS FORM ALLOWS PARENTS /LEGAL CUSTODIAN TO DESIGNATE WHICH OTHER ADULTS WILL MAKE MEDICAL DECISION FOR A CHILD IN THE ABSENCE OF PARENTS/LEGAL CUSTODIAN.PARENT'S /GUARDIAN'S DELEGATION OF AUTHORITY TO CONSENT TO MEDICAL TREATMENT OF MINOR CHILD.
a minor child, do hereby authorize the individuals listed below to act as agents for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and / or hospital care to be rendered to said minor child under the supervision of a physician and surgeon licensed or any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor by a physician.
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 on the part of the said agents to give specific consent to any and all such diagnosis, treatment, or hospital care which a physician and surgeon in the exercise of his or her best judgement may deem advisable.
INDIVIDUALS AUTHORIZED TO CONSENT TO MEDICAL TREATMENT OF MINOR CHILD (LIST INDIVIDUALS OTHER THAN PARENTS OR GUARDIANS OF MINOR)
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This authorization shall remain in effect, unless revoked in writing and delivered to Phoenix Pediatrics, LTD
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