Temporary Authorization to Consent to Treat a Child

I (we)_____________________________________________________________

                   Name(s) and address(es) of parents



designate to _______________________________________________________

                      Name and address of designee

the power to consent in our absence to medical care for our

child(ren):



_________________________________    _______________________________

Name(s) and age(s) of  child(ren)



_________________________________    _______________________________



Parent(s)' phone number: __________________________________________

Child(ren)'s physician(s): ________________________________________

Physician's address and phone number: _____________________________

___________________________________________________________________

Medical insurance company: ________________________________________

Policy #: _________________________________________________________

Dates of expected absence from ________________ to ________________





CHILD(REN)'S MEDICAL HISTORY 



Chronic conditions________________________________________________

Medications that need to be given on a regular basis:

___________________     __________________________________________

Child's Name             Medication name, dosage, frequency

___________________     __________________________________________

Child's Name             Medication name, dosage, frequency

___________________     __________________________________________

Child's Name             Medication name, dosage, frequency



Allergies:________________________________________________________

Dietary or other restrictions: ___________________________________

Written by Robert Brayden, MD, Associate Professor of Pediatrics, University of Colorado School of Medicine.
Published by RelayHealth.
© 2009 RelayHealth and/or its affiliates. All Rights Reserved.