Temporary Authorization to Consent to Treat a Child

 
I (we)_____________________________________________________________
                   Name(s) and address(es) of parents

designate to _______________________________________________________
                      Name and address of designee
the power to consent in our absence to medical care for our
child(ren):

_________________________________    _______________________________
Name(s) and age(s) of  child(ren)

_________________________________    _______________________________

Parent(s)' phone number: __________________________________________
Child(ren)'s physician(s): ________________________________________
Physician's address and phone number: _____________________________
___________________________________________________________________
Medical insurance company: ________________________________________
Policy #: _________________________________________________________
Dates of expected absence from ________________ 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: ___________________________________
Written by Robert Brayden, MD, Associate Professor of Pediatrics, University of Colorado School of Medicine.
Published by RelayHealth.
Last modified: 1999-06-03
Last reviewed: 2009-06-23
This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.
© 2009 RelayHealth and/or its affiliates. All Rights Reserved.