Permission for Treatment

Permission for Treatment for Your Child

Any time your child requires medical care, whether for a minor ailment, such as an car infection, or a more serious injury, such as a fracture or burn, you want your child to receive medical care as quickly as possible. In today's world, you cannot always be there. By completing the following Power of Attorney for Consent to Medical Care, you are authorizing the person named in the form to consent for treatment of your child in your absence. The person you authorize may be a baby-sitter, neighbor, grandparent or any other responsible adult you trust, who is available to obtain medical treatment for your child in your absence.

The attached Power of Attorney Form is valid for one year and must be updated annually. A separate form must be completed for each child.

A medical history section is included in this form. While it is not required to validate the Power of Attorney, it would be useful to medical personnel as they provide care for your child in your absence.

Of course, if your child's injury or illness is a medical emergency, medical personnel are authorized by law to provide treatment even if you or the individual named in the Power of Attorney form are not available.

If you have any questions regarding this form, please consult your attorney.

Power of Attorney to Consent to Medical Care for a Minor

By signing this form below, I (we) hereby authorize ___________________________ to consent to any medical care and treatment for ______________________________ ("Child") that is recommended by a licensed health care provider to whom the Child is presented for treatment. In order to ensure that the Child receives prompt medical care and treatment when necessary, I (we) hereby release any licensed health care provider providing medical care to the Child in reliance of this form from liability relating to such provider's acceptance of my (our) substitute care giver's consent.

This Power of Attorney is dated _____________________ and is valid for one year.

Parent's Signature _____________________________________Date__________

Parent's Signature _____________________________________Date__________
(second signature optional)

Dated______________

_______________________________________

Notary Public

My commission expires ____________________

Medical History

(Failure to complete any of the following does not impair the validity of this Power of Attorney to consent to medical care for a minor.)

Child's Name__________________________________________

Child's Birth Date ______________________________________

Allergies _____________________________________________

Blood Type ___________________________________________

Religion______________________________________________

Previous Hospitalizations and Major Illnesses ________________

_____________________________________________________

Current Medications ______________________________f_____

Date of Last Tetanus Shot / Other Innoculations ________________

_____________________________________________________

Pediatrician _____________________ Telephone ___________

Other Important Information

Other Information

Name ______________________________________________

Home Address _______________________________________

Home Phone ________________________________________

Place of Employment __________________________________

Work Phone _________________________________________

Insurance Company ___________________________________

Policy Number _______________________________________

Mother's Name _______________________________________

Home Address _______________________________________

Home Phone ________________________________________

Place of Employment _________________________________

Work Phone ________________________________________

Insurance Company __________________________________

Policy Number _______________________________________

The Carson Law Firm: Family Law Attorneys -- Serving St. Louis Families for Over a Decade

Send mail to familylawinfo@thecarsonlawfirm.com with questions or comments about this web site.

This web site is designed for general information only. The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship. Persons accessing this site are encouraged to seek counsel for advice regarding their individual legal issues.

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