Notice to Revoke "Designation of Another Person to Consent for Treatment"

Notice to Revoke "Designation of Another Person to Consent for Treatment"
Parent/ Legal Guardian's Name*

First NameLast Name
Patient's Name*

First NameLast Name
Patient's DOB*

MonthDayYear
Date
Name of Person Who Is Being Revoked*

First NameLast Name
I, {parentLegal}, am legally responsible for {patientsName} born on {patientsDob}. Please immediately revoke prior permission for {nameOf} to consent for treatment of my child.
Signature of Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date
Signature of Witness 18 Years or Older:*

Clear
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*

Area CodePhone Number
Email*
example@example.com
Should be Empty: