Grandparent Consent to Treat Minor Form

Grandparent Consent to Treat Minor Form
Use this form to authorize a grandparent or legal guardian to consent to medical treatment for a minor when the parent or guardian cannot be reached.
Grandparent/Guardian Full Name
First NameLast Name
Relationship to Minor
Grandparent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Grandparent/Guardian Email Address
example@example.com
Minor’s Full Name
First NameLast Name
Minor’s Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Caregiver or Clinic Authorized to Provide Treatment
Alternate Emergency Contact Name and Phone Number
Consent Declaration
Signature of Grandparent/Guardian
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