AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF CHILD
____________________, male, born March 8, 2014 at ____________________ and residing at ____________________, ____________________, Virginia, __________, ____________________.
I do not authorize ____________________ to consent to the transfusion of blood.
Name: ____________________Street Address: ____________________City, State: ____________________, VirginiaZipcode: Country: ____________________Home Phone: (______) ______-________Work Phone: (______) ______-________Cell Phone: (______) ______-________Email: ____________________
IN WITNESS WHEREOF, I hereunto sign my name at ____________________, Virginia this 8th day of March, 2014.
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