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Carr Dermatology

Authorization for Medical Treatment of Minors


  Last name

  Mid name

  First name

If your child needs medical services, you a parent must give permission. What about times when you cannot be reached for permission? A child may be treated without parental consent when a physician determines a true emergency exists. That means the doctor determines the child needs immediate medical care and that an attempt to obtain parental consent would result in a delay which would increase the risk to the child’s life or health.
Except in a true emergency, care may be ordinarily rendered to a child only with the consent of the parent or legal guardian. Sometimes a child may need unexpected care which is not however, a true emergency. In such cases, making an effort to contact a parent for permission can delay treatment and create unnecessary anxious moments for the child.
You can prepare for unexpected care your children might need when you are away from home. To do this, make sure babysitters know how to reach you at all times. And when you know you will be hard to reach, you can give permission to other adults. They can then act for you by permitting your child to be treated if unexpected care is needed.
This is a legal document. With it you may appoint relatives, friends, teachers, clergy, neighbors-any one who is over 18 years of age to be responsible for your children when you are a away from them. It is especially important to prepare this form for the occasions, when you know it will be hard to contact you.
* I hereby give dr. Carr and her staff permission to examine and provide medical treatment for the following minor. I understand that the first office visit dr. Carr recommends the minor to be acompanied by a parent.
Please fill out the information below only if minor is unable to drive themselves or parent is unable to bring minor. This information is for unexpected care when the parents are unavailable.
Person You Appoint to Represent You:

(Your digital signature (full name) is as legally binding as a physical signature.)