Proxy Medical Consent Form
A Proxy Medical Consent Form should be completed and a copy left with anyone, other than the parents, who are caring for children under 18.
Examples would be:
- Parents are going out of town for the weekend and the children are staying with grandparents.
- Parents are going out of town and leaving children with a sibling who is over 18 years of age.
By signing, and having a witness sign, you authorize those persons listed in the permission section to have your children treated, and you realize that you will be billed for the services.
It is always important to have medical history, including allergies, when treatment is needed.
Proxy Medical Consent Form PDF