Designation of Another Person To Consent For Treatment

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
Witness of 18 Years or Older

First NameLast Name
I, {parentLegal}, cannot accompany my child, {patientsName}, born on {patientsDob} to a Medical Health Associates Member Facility. Therefore, I give permission to {witnessOf} as follows (check one):
Effective Date:

MonthDayYear
Date
Expiration Date:

MonthDayYear
Date
Signature of Parent or Legal Guardian:
Date

MonthDayYear
Date
Signature of Witness 18 Years or Older:
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

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