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I, ______________________, the parent or legal guardian of ______________________,
residing at ______________________________________________________ [Address]
born on the ___ day of _______________________, 20___ do hereby consent and allow
______________________ [Grandparent] to handle any type of medical care for my child
including but not limited to the administration of anesthesia determined by a physician, surgery,
and any other care recommended or deemed as necessary for the welfare of my child.
This authorization is effective from on this ___ day of _______________________, 20___ and
expires on the ___ day of _______________________, 20___
_____________________________________ ___________ _____________________
Signature of Parent or Legal Guardian Date Print Name
_____________________________________ ___________ _____________________
Signature of Witness Date Print Name
This consent form should be taken with the child to the hospital or physician's office when the
child is taken for treatment. This additional information will assist in treatment if it can be
furnished with the consent but is not required.
Father’s Telephone: _____________________ Mother’s Telephone: _____________________
Allergies to drugs or foods: ______________________________________________________
Special Medications, Blood Type or Pertinent Information: ______________________________
Child's Physician: __________________________ Phone: ________________
Insurance: ________________________________ Policy # ________________
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A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate
is attached, and not the truthfulness, accuracy, or
validity of that document.
State of ____________________________)
County of ____________________________)
On ____________________________ before me, ____________________________
(insert name and title of the officer)
personally appeared ____________________________, who proved to me on the basis of
satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of ________________________
that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature (Seal)
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