Designation of Health Care Surrogate for a Minor
All children under the age of 18 need to have the Authorization to Treat A Minor form completed. This form provides Community Health Centers with a list of individuals able to bring the child in for medical or dental treatment.
Name of Minor
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Parent, Legal Guardian, or Legal Custodian
First Name
Last Name
Additional Parent, Legal Guardian, or Legal Custodian
First Name
Last Name
Relationship to Patient
Please Select
Parent
Legal Guardian
Legal Custodian
Additional Consent
Please list all additional individuals you would like to give consent to bring the child in for medical or dental treatment.
(1) Name of Person to Give Consent
First Name
Last Name
(1) Relationship to Patient
Please Select
Grandparent
Brother / Sister
Family Friend
Teacher
Other
(1) Phone Number
Please enter a valid phone number.
(1) Address
Would you like to add an additional individual?
Yes
No
(2) Name of Person to Give Consent
First Name
Last Name
(2) Relationship to Patient
Please Select
Grandparent
Brother / Sister
Family Friend
Teacher
Other
(2) Phone Number
Please enter a valid phone number.
(2) Address
Notification of Surrogate
I/We will notify and send a copy of this document to the following person(s) other than my/our surrogate, so that they may know the identity of my/our surrogate.
(1) Name of Who to Notify
(2) Name of Who to Notify
Parent, Legal Guardian, or Legal Custodian Signature
*
Date
*
-
Month
-
Day
Year
Date
All notices and agreements can be download from our
Patient Resources
page.
Submit
Should be Empty: