Temporary Medical Authorization for Minor Form

Minor's Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Age

Current Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Primary Doctor / Pediatrician Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent / Legal Guardian Full Name

First NameLast Name

Relationship to Minor

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Preferred Contact Method

Other

Authorization Start Date

Date

Authorization End Date and Time

Date

Hour MinutesAM/PM Option

Reason for Temporary Authorization

Permitted Care Categories

Special Instructions or Restrictions

Authorization Acknowledgment: I confirm that I am the parent/legal guardian and authorize the care described above for the time period indicated.

Parent / Legal Guardian Signature

Known allergies

Current medications and dosage instructions

Existing medical conditions

Recent injuries or illnesses

Immunization or other relevant medical notes

Special medical needs or precautions

Emergency Contact 1 Name

First NameMiddle NameLast Name

Emergency Contact 1 Relationship to Minor

Emergency Contact 1 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact 2 Name

First NameMiddle NameLast Name

Emergency Contact 2 Relationship to Minor

Emergency Contact 2 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Authorized Adults for Pickup or Accompaniment

Other

May the caregiver seek emergency treatment if the guardian cannot be reached?

Preferred hospital, urgent care center, clinic, or healthcare provider

Preferred pharmacy

Special instructions for treatment, transportation, or communication

Temporary Medical Authorization for Minor Form

Minor Information

Parent / Legal Guardian Information

Temporary Authorization Details

Medical Information for the Minor

Emergency Contact and Pickup Authorization

Preferred Care and Instructions