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):
I give permission for this person to seek treatment (including any type of procedure, medication administration, vaccination, test, mental health care, etc) and provide consent for such treatment if attempts to contact me are unsuccessful.I give permission for this person to seek treatment (including any type of procedure, medication administration, vaccination, test, mental health care, etc) and provide consent for such treatment without having to contact me.
Effective Date:*

MonthDayYear
Date
Expiration Date:

MonthDayYear
Date
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 Number*

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