Pediatric Authorization for Medical Treatment and Care

Patient Information

Child's Full Name: _________________________ Date of Birth: //___ Address: ______________________________________________________

Parent/Legal Guardian Information

Name: _________________________________ Relationship: ____________ Phone: (Home) _____________ (Work) _____________ (Cell) _____________

Emergency Contact (other than parent/guardian)

Name: _________________________________ Phone: _________________ Relationship to Child: _____________________

Authorization Statement

I, _________________________, as parent/legal guardian of the above-named minor patient, hereby authorize [PRACTICE NAME] and its medical staff to provide medical care and treatment to my child. This authorization includes:

• Routine medical examinations and well-child visits
• Immunizations and diagnostic tests
• Emergency medical care when deemed necessary
• Administration of prescribed medications
• Treatment of acute illnesses and injuries

Medical Information

Allergies: __________________________________________________ Current Medications: ________________________________________ Chronic Medical Conditions: __________________________________

Consent Duration

This authorization is valid until: □ Child reaches 18 years of age □ Date: //___ □ Other: ________________________________________________

Authorization Signature

Signature: _________________________ Date: //___ Printed Name: _____________________

Witness

Signature: _________________________ Date: //___ Printed Name: _____________________