PRE-AUTHORIZATION FOR THIRD PARTY
TO CONSENT TO
TREATMENT OF MINOR LACKING CAPACITY TO CONSENT
(I)(We), the undersigned, parent(s)/person having legal custody/legal guardianship of (name of minor)________________________________________, a minor, do hereby authorize (name of agent)________________________________________, as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the physician or at the hospital.
It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority to the above described agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which a physician, meeting the requirements of this authorization, may, in the exercise of his/her best judgement, deem advisable.
This authorization is given pursuant to the provisions of Family Code section 6910.
(I)(We) hereby authorize any hospital which has provided treatment to the above-named minor pursuant to the provisions of Family Code section 6910 to surrender physical custody of such minor to (my)(our) above-named agent(s) upon the completion of treatment. This authorization is given pursuant to Health and Safety Code section 1283.
These authorizations shall remain effective until (month and day)__________________, 20______, unless sooner revoked in writing delivered to the agent(s) noted above.
Date:___________________________________
Signature:________________________________________________________________________
(Relationship to Minor)
Signature:________________________________________________________________________
(Parent___ Guardian____ Person having legal custody___)
MEDICALLY RELEVANT INFORMATION
Minor’s Name:_______________________________________________________________________
Minor’s Birthdate:____________________________________________________________________
Allergies to drugs or food:______________________________________________________________
Conditions for which minor is currently being treated: ___________________________________________________________________________________
___________________________________________________________________________________
Current medications:__________________________________________________________________
Restrictions on activity:________________________________________________________________
Primary care physician (name and telephone number): ___________________________________________________________________________________
Insurance Company:__________________________________________________________________
Mother’s Name:______________________________________________________________________
Mother’s address:_____________________________________________________________________
Mother’s telephone numbers: Work ( ) Home ( ) Other ( ) .
Father’s Name:_______________________________________________________________________
Father’s address:_____________________________________________________________________
Father’s telephone numbers:
Work ( ) Home ( ) Other ( ) .