Temporary Consent Authorization to Treat a Child

Procedure/Treatment: __________________________________________________________

I (we) ________________________________________________________________________ [name(s) of parent(s) or guardian(s)]

designate to ___________________________________________________________________ [name and address of designee]

the power to consent to medical care for our child(ren) in our absence:

____________________________ [name and age of child] ____________________________ [name and age of child]

____________________________ [name and age of child] ____________________________ [name and age of child]

Parent(s)' phone number: _______________________________________________________

Child(ren)'s physician(s): ________________________________________________________

Physician's address and phone number: ___________________________________________

_____________________________________________________________________________

Interpreter Name (if used): ______________________________________________________

Medical insurance company: __________________________ Policy #: ___________________

Dates of expected absence from school/work: _________________ to __________________

CHILD(REN)'S MEDICAL HISTORY

Chronic conditions: _____________________________________________________________

Medications that need to be given on a regular basis:

____________________ [child's name] _____________________________________________ [medication name, dosage, frequency]

____________________ [child's name] _____________________________________________ [medication name, dosage, frequency]

____________________ [child's name] _____________________________________________ [medication name, dosage, frequency]

Allergies: ______________________________________________________________________

Dietary or other restrictions: ______________________________________________________