Minor (Child) Medical Consent Form
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CONSENT TO TREAT MINOR CHILDREN
I, _______________________, parent or legal guardian of _______________________, born
the ___ day of _______________________, 20___ do hereby consent to any medical care and
the administration of anesthesia determined by a physician to be necessary for the welfare of
my child while said child is under the care of _______________________ of
_______________________, City of ____________ State of ____________ and I am not
reasonably available by telephone to give consent.
This authorization is effective from the ___ day of _______________________, 20___ to
___ day of _______________________, 20___

_____________________________________
Signature of Parent or Legal Guardian

__________________
Date

______________________________
Witness Signature

______________________________
Witness Name (please print)

This consent form should be taken with the child to the hospital or physician's office when the
child is taken for treatment. This additional information