AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR

(I) (We) , the undersigned, parent(s) of ____________________ a minor, do hereby authorize _________________(sponsor) to act as designee for the above named minor to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is prescribed by, and is to be rendered under the special supervision of, any licensed physician surgeon, whether such diagnosis or treatment is rendered at the office of said physician/or surgeon or at a hospital or elsewhere.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being rendered and is given to provide authority and power on the part of our aforesaid designee to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician surgeon may, for reasons he/she deems appropriate, prescribe.

(I) (We) hereby authorize any hospital which has provided treatment to the above named minor to surrender physical custody of such minor to (my) (our) named designee (s) upon completion of treatment.

This authorization is given for designee(s) for the period _______ - _______ 2008.

This authorization is not to be construed as releasing any physician or surgeon from any requirement that he or she adhere to the lawful standard of care in attending to the named minor and is not to be construed as creating any financial responsibility on the part of the designee(s) for any health care provided the named minor.

PARENTS ARE RESPONSIBLE FOR PAYMENT.

This authorization shall become effective as of __________ 2008 and remain effective until ____________, 2008.

______________________________

Parent or Legal Guardian (Signature)

(Please Print)

Name _____________________________

Address ______________________________

______________________________

Phone ______________________________