AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF CHILD
____________________, male, born July 30, 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 30th day of July, 2014.
A Child Medical Consent is also known as:
A Child Medical Consent is a document which allows parents or guardians to authorize another party to consent to their child's medical treatment.
A Child Medical Consent should be used by parents or guardians who may be unable to personally consent to their child's medical treatment due to travel or other situations where the children will be in the care of others.
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