Authorization to consent to health care for minors

Please correct the errors described below.

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parent/guardian name
county of residence

county North Carolina, am the custodial parent/guarding having legal custody of

In my absence, the following person(s) have permission to make decisions and/or obtain information regarding my child’s health care. Such duties may include but are not limited to: [1] the power to provide for such health care at any hospital or institution, or the employing of any physician, dentist, nurse, or other person whose services may be needed for such health care and [2] consent to and authorize any health care, including administration of anesthesia, x-ray examination, performance or operations, and other procedures by physicians, dentists, and other medical personnel except the withholding or withdrawal of life sustaining procedures.

Names of Authorized Persons whom have the above listed permissions:

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This signed consent shall be effective from the date of my signature, if any changes are needed, then I will need to update this information with another signed consent.

By signing below, I indicate that I have understanding and the capacity to communicate health care decisions and that I am fully informed as to the consents of this document and understand the full import of this grant of powers to the agent named herein. Furthermore, I may request to change or update this form at any time.

In addition to the statement above, I am aware and fully understand that a responsible adult has to be with the patient/s at all times, from arrival to check out time. Also, no verbal consent is allowed via phone or email.

**Witness may not be the person designated by the parent to consent to healthcare for minors 18 years or older.

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