PARENT PERMISSION AND MEDICAL CONSENT FORM
Child Name: Birthdate: _______
Social Security # Grade:
City: State: Zip:
Home Phone: ( ) Work Phone: ________
(I) (We), the undersigned, parent(s) of , a minor, do hereby consent to said Minor participating in (explain activity) conducted by .
Authorization of Consent to Treatment of Minor:
(I) (We), the undersigned, parent(s) of , a minor, do hereby authorize , hereinafter “Agent”, for and on behalf of 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 specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital, during all times that the Minor is in the presence of said Agent.
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 and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable and release Agent from all damages of same.
This authorization shall remain effective through the __ day of , 20 , unless sooner terminated in writing.
Home Phone Work Phone
Other phone number
Legal Guardian Phone
Other Emergency Contact Phone
Family Doctor Phone
Insurance Co. If None Please Check
Insurance Policy Name and #
Known Medical Conditions
Last Tetanus Immunization?
Will You Allow Blood Transfusions? (__) Yes (__) No
State Specific Parental Permission Forms
–For State Specific Parental Permission Forms you can download in Word format, go to