Pediatric Medical Consent by Proxy Form
Authorize pediatric medical care for a minor by a parent, legal guardian, or designated proxy.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Proxy/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Parent
Legal Guardian
Grandparent
Relative (Specify Below)
Family Friend
Other (Specify Below)
If 'Relative' or 'Other', please specify
Basis for Authorization
*
I am the parent or legal guardian
I am authorized by the parent/legal guardian in writing
Other
Medical Treatment Scope
*
Any necessary medical care
Only emergency care
Only specific treatments (specify below)
If 'Only specific treatments', please specify
Relevant Medical History (allergies, medications, conditions)
*
Emergency Contact Name & Phone Number
*
Signature of Parent/Guardian/Proxy
*
Submit Consent
Submit Consent
Should be Empty: