Child Medical Procedure Permission Form

I,First Name   Last Name, am the Parent or Legal Guardian of the child(ren) listed below and there are no court orders in effect that would prohibit me from conferring the power to consent upon another person.

I,Name of Parent orLegal Guardian or Custodian, do hereby confer upon   Name of Parent or   Legal Guardian or Custodian residing at   1 the power to consent necessary medical or mental health treatment for the following child(ren):

1. First Name   Last Nameand Birthdate  , Residing at:   2  
2. First NameLast Name and Birthdate, Residing at:   3   
3. First Name   Last Nameand Birthdate , Residing at:   4   

and on the child(ren)'s behalf do hereby state that the power to consent that I confer shall not be affected by my subsequent disability or incapacity.

The power that I confer is limited to health care and mental health care decision making, and it may be practiced only by the person who is names above.

The person named above may consent to following examinations and treatment for my child(ren):

Medical   Surgical   Mental Health   Immunizations   Development   Dental    Other       

and may have access to any and all records, including but not limited to insurance records regarding any such services.

I confer the power to consent freely and knowingly in order to provide for the child(ren) and not as a result of pressure, threats or payments by any person or agency. This document shall remain in effect until it is revoked by my written notification to my child(ren)’s medical, mental health care, and insurance providers, and the person named above.

In witness hereof, I have signed my name to this medical consent authorization, on   Date .

Parent or Legal Guardian NameFirst Name   Last Name   

Parent or Legal Guardian Signature   Signature   

Witness Name   First Name   Last Name   

Witness Signature   Signature