Permission to Treat a Minor



This consent shall remain effective until __________,
20______

I (we) the undersigned parent, parents or legal guardian of
________________________________________________ a minor, do hereby
authorize and consent to any x-ray examination, anesthetic, medical or
surgical diagnosis rendered under the general or special supervision of
any member of the medical staff and emergency room staff licensed under
the provisions of the Medicine Practice Act , of a Dentist licensed
under the provisions of the Dental Practice Act, and on the staff of any
acute general hospital holding a current license to operate a hospital
from the State of California Department of Public Health. 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 to render care which the aforementioned
physician in the exercise of his best judgment may deem advisable. It is
understood that effort shall be made to contact the undersigned prior to
rendering treatment to the patient, but that any of the above treatment
will not be withheld if the undersigned cannot be reached.

List any
restrictions:_____________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Signature of Father, Mother or Legal
Guardian:________________________________________________________________Date:___________

Address:____________________________________
City:__________________________ State:______ Zip:_________

Birth
Date:_________________________________________________________________________________

Last Tetanus Toxoid Booster:
______________________________________________________________

Allergies to Drugs or Foods:
_______________________________________________________________________

Any Special Medications

Or Pertinent
Information:___________________________________________________________________________

____________________________________________________________________________________

Telephones Where Parents May Be Reached

Father:____________________________________
Home:_________________________ Work:____________________

Mother:___________________________________
Home:_________________________ Work:____________________

Family
Physician:________________________________________________________________________

Address:____________________________________
City:__________________________ State:______ Zip:_________

Insurance Company:
___________________________________________________Policy
No._____________________


Start Your Nanny Career Today

enter your zip code: