Medical Consent for Minor by Appointed Guardian

Minor Information

Address

Guardian Information

Full Name Address

Parent/Legal Custodian Information

Full Name

Medical Information

Physician Name Physician Phone Number Known Allergies Current Medications Other Medical Concerns or Instructions

Consent

I, the undersigned, as the parent/legal guardian of the minor named above, hereby authorize the appointed guardian to consent to any necessary medical examination, anesthetic, medical diagnosis, surgery, or treatment and/or hospital care for the minor named above under the general or special supervision and upon the advice of any physician, surgeon, or dentist licensed to practice.