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Authorization For Agent To Consent To Medical Treatment Of A Minor (California)

This form authorizes an agent to consent to medical treatment of a minor in California. The form provided here is simply a sample of what the actual form looks like.

AUTHORIZATION FOR AGENT TO CONSENT TO MEDICAL TREATMENT OF A MINOR

I hereby authorize ___________________________________ (an adult into whose care the minor(s) has been entrusted) to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care of

___________________________________ (name(s) of minor(s)) deemed advisable by a licensed physician and surgeon and provided by that physician or under that physician's supervision, regardless of where that treatment is provided.

This authorization is made under Family Code §6910.

Signed: ___________________________________

Dated: ___________________________________

Print Name: ___________________________________

Please specify relationship to minor:

[___] parent with legal custody

[___] guardian with legal custody


© California Medical Association 1999
As a public service of the California Medical Association, reproduction of this document by individuals for personal use and not for commercial purposes is authorized as long as each copy clearly includes this copyright notice.

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