Medical Consent Form

Authorization by parents for another to consent to hospitalizations, surgery or medical procedures during absence of parent(s)/guardian(s).

Date:

Parent/Guardian Name(s):

Name(s) of child (children)

First Name

Last Name

Birthdate

First Name

Last Name

Birthdate

First Name

Last Name

Birthdate

First Name

Last Name

Birthdate

First Name

Last Name

Birthdate

I/We hereby appoint

Name

Phone number

Relationship to patient

Name

Phone number

Relationship to patient

Name

Phone number

Relationship to patient

Name

Phone number

Relationship to patient

As the person(s) who during my/our absence shall be authorized to consent for all medical and/or surgical treatment and/or special procedures (including by way of illustration and not limitation, administration, blood transfusion, diagnostic tests, etc) which may be required during my/our absence. Without in any manner limiting the foregoing appointment and authorization. If circumstances permit, I/We would like to have our doctor consulted in connection with such medical and/or surgical treatment and/or special procedures.

List allergies and current medications, if any

Edgewood Center Pediatrics P.C., its officers and personnel and any physician providing care are authorized by the above named to act as appointee with the same force and effect as if personally executed by me/us.

The consent and authorization shall include and extend to all matters for which consent, or authorization is required under the policies of Edgewood Center Pediatrics P.C. In consideration of the services which are rendered to any child, named above, pursuant hereto, we agree to pay for all services. This authorization shall be effective until revoked in writing.

Parent(s)/Guardian(s)

Typed Name

Date