Appendix D: authorization for consent to medical treatment of minor.

AUTHORIZATION FOR CONSENT TO MEDICAL TREATMENT OF MINOR

I, -- being the parent entitled to the legal and physical custody of my minor child --, born --, do hereby authorize --, into whose care the child has been entrusted, to consent to any X-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care to be rendered to said child under the supervision and upon the advice of a physician or other medical care provider licensed to practice medicine in any state in the United States. I further authorize --, to consent to any X-ray, examination, dental, or surgical diagnosis or treatment and hospital care to be rendered to said minor child by a dentist licensed to practice dentistry in any state in the United States.

This shall be valid from -- to --. Executed this -- day of --, 20 --, at --.

--

Signature of Principal

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

 
State of --) 
          ) SS. 
County of --) 
On -- before me, --, personally 
 (Date)        (Notary) 
appeared -- 
       Signer(s) 
 
Personally known to me - OR -          proved to me on the basis of 
                                       satisfactory evidence to be the 
                                       person(s) whose name(s) is/are 
                   ...