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AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF CHILD
I, ____________________ of ____________________, ____________________, $state, __________, ____________________ make oath and say that I am the lawful guardian of the child listed below and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.
Information of Child
____________________, male, born $month $day, $year at ____________________ and residing at ____________________, ____________________, $state, __________, ____________________.
I hereby authorize and appoint ____________________ of ____________________, ____________________, $state __________ as my agent. My agent may consent to my child's medical examination or treatment. Such treatment may include but is not limited to the following:
transportation by ambulance
I do not authorize ____________________ to consent to the transfusion of blood.
The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for my child and this power and authority will be effective as of the $day day of $month, $year.
I give this consent freely and knowingly in order to provide for the child and not as a result of pressure, threats or payments by any person or agency.
This consent will remain in effect until it is revoked by notifying my child's medical, mental health care and insurance providers, in writing, and the agent named above that I wish to revoke it.
Any questions or concerns regarding this authorization may be directed to me at:
Name: ____________________ Street Address: ____________________ City, State: ____________________, $state Zipcode: __________ Country: ____________________
Home Phone: __________ Work Phone: __________ Cell Phone: __________ Email: ____________________
IN WITNESS WHEREOF, I hereunto sign my name at ____________________, $state this $day day of $month, $year.
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