"Permission to Treat Without Parents Accompanying Child"

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PERMISSION TO TREAT WITHOUT PARENTS ACCOMPANYING CHILD
This form gives a medical facility/clinic permission to treat the below-referenced child without being
accompanied by his/her parents, _________________________________.
Child’s Name
Date of Birth
Home Address
SSN
Father’s Name
Home Phone
Home Address
Cell Phone
Employer’s Name
Work Phone
Employer’s Address
Mother’s Name
Home Phone
Home Address
Cell Phone
Employer’s Name
Work Phone
Employer’s Address
Emergency Contact
Home Phone
Home Address
Cell Phone
Allergies
Special medications
Other Information
Pediatrician
Preferred Hospital
Name of insurance
Address
Policy Holder Name
SSN
Policy ID No.
Group No.
I hereby grant, _________________________________, (relationship), (address), (phone),
permission to authorize treatment for the above-listed child.
___________________________________
______________________________________
NAME
Date
Name
Date
State of _______________)
§
County of ______________)
On this day ________ of _____________, _____, before me, _____________________________, a
notary public, personally appeared, _____________________________, proved on the basis of
satisfactory evidence to be the person(s) whose name(s) (is/are)subscribed to this instrument, and
acknowledged (he/she/they) executed the same. Witness my hand and official seal.
______________________________________
N
P
OTARY
UBLIC
SEAL
PERMISSION TO TREAT WITHOUT PARENTS ACCOMPANYING CHILD
This form gives a medical facility/clinic permission to treat the below-referenced child without being
accompanied by his/her parents, _________________________________.
Child’s Name
Date of Birth
Home Address
SSN
Father’s Name
Home Phone
Home Address
Cell Phone
Employer’s Name
Work Phone
Employer’s Address
Mother’s Name
Home Phone
Home Address
Cell Phone
Employer’s Name
Work Phone
Employer’s Address
Emergency Contact
Home Phone
Home Address
Cell Phone
Allergies
Special medications
Other Information
Pediatrician
Preferred Hospital
Name of insurance
Address
Policy Holder Name
SSN
Policy ID No.
Group No.
I hereby grant, _________________________________, (relationship), (address), (phone),
permission to authorize treatment for the above-listed child.
___________________________________
______________________________________
NAME
Date
Name
Date
State of _______________)
§
County of ______________)
On this day ________ of _____________, _____, before me, _____________________________, a
notary public, personally appeared, _____________________________, proved on the basis of
satisfactory evidence to be the person(s) whose name(s) (is/are)subscribed to this instrument, and
acknowledged (he/she/they) executed the same. Witness my hand and official seal.
______________________________________
N
P
OTARY
UBLIC
SEAL