AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF CHILD
____________________, male, born December 22, 2014 at ____________________ and residing at ____________________, ____________________, Manitoba, __________, ____________________.
I do not authorize ____________________ to consent to the transfusion of blood.
Name: ____________________Street Address: ____________________City, Province/Territory: ____________________, ManitobaPostal Code: Country: ____________________Home Phone: (______) ______-________Work Phone: (______) ______-________Cell Phone: (______) ______-________Email: ____________________
IN WITNESS WHEREOF, I hereunto sign my name at ____________________, Manitoba this 22nd day of December, 2014.
Note: Your initial answers are saved automatically when you preview your document.This screen can be used to save additional copies of your answers.