|I/We, ________________________________________________, am/are the parent(s) of _____________________________________________, born [date of birth for each minor child]_______________________________________. I am/We are placing my/our child(ren) into the care of ____________________________________ during our absence. I/We authorize __________________________________ to consent to any medically necessary X-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care recommended for the benefit of my/our child(ren). Such medical care is to be rendered to said child under the care, supervision, and advice of a physician or other medical care provider licensed to practice medicine in any state in the United States. I/We further authorize ________________, to consent to any X-ray, examination, dental or surgical diagnosis or treatment, and hospital care to be rendered to my/our minor child(ren) by a dentist licensed to practice dentistry in any state in the United States.|
This authority shall be valid from ________________ to ______________, 20__.
Executed this ______ day of ____________________, 20__ at ______________, ________.
State of _________________________
County of _______________________
On ________________, 20__, _________________________________________
________________, personally appeared before me and executed this document. WITNESS my hand and official seal.