_______________________________________,
____________________________________
(LAST NAME) (minor child)
(FIRST NAME)
CONSENT TO MEDICAL TREATMENT
I, _____________________________, the (parent)
(guardian) of __________________________________________,
a minor child whose birth date was_________________, 19______ and who is the
child of __________________________
and _____________________________________ hereby authorizes any duly authorized
doctor, hospital or other medical
facility to treat said minor on or after _______________________________20____
for the purpose of attempting to treat or
relieve any injuries received by said minor while he was a participant or
observer at________________________________
_______________________________________________________________________________________________
I
authorized any licensed physician to perform any procedure which he deems
advisable in attempting to treat or relieve
any injuries or any related unhealthy
condition of said minor that he may encounter during any necessary operation.
I consent to the administration of anesthesia as deemed advisable by any licensed physician.
I
realize and appreciate that there is a possibility of complications and
unforeseen circumstances in any medical
treatment and I assume any such risk
on the behalf of myself and said minor. I acknowledge that no warranty is
being made as to the result of any
treatment.
____________________________________________
___________________________________________
(NAME)
(RELATIONSHIP TO MINOR)
STATE OF _________________ §
COUNTY OF________________ §
BEFORE ME, a Notary Public in and for said County and State, personally
appeared_________________________
__________________________________who acknowledged that he has read the above
and forgoing instruments and
that the execution of both was his voluntary act and deed and that all
statements therein are true and correct.
Witness my hand and seal this _____________day of __________________________________, 20____________.
__________________________________________________
Notary Public and for
_______________________County,_____________________
My Commission Expires_______________________________