CONSENT TO MEDICAL TREATMENT FORM FOR MINOR
(LAST NAME) (minor child)
CONSENT TO MEDICAL
the (parent) (guardian) of ___________________________,
A minor child whose birth
date was__________________,____________________ and who is the child of
Authorizes any duty
authorized doctor, hospital or other medical facility to treat said minor on or
the purpose of attempting to treat or relieve any injuries
Received by said minor while
he was a participant or observer at __________________________________
I authorize any licensed
physician to perform any procedure which he deems advisable in attempting to
treat or relieve any injuries or any related unhealthy condition of said minor
that he may encounter during any necessary operation.
I consent to the
administration of anesthesia as deemed advisable by any licensed physician.
I realize and appreciate
that there is a possibility of complications and unforeseen circumstances in any
medical treatment and I assume any such risk on the behalf of myself and said
minor I acknowledge that no warranty is being made as to the results on any
NAME RELATIONSHIP TO MINOR
BEFORE ME, a Notary Public
in and for said County and State, Personally appeared _________________
who acknowledged that he/she has read the above and foregoing instruments and
that the execution of both was his/her voluntary act and deed and that all
statements are true and correct.
Witness my hand and seal
this_______________________ day of ___________________,____________.
Notary Public in and for
My Commission Expires:______________________