While any emergency room will treat a life and death situation, they will not provide treatment to a minor brought in by someone other than a parent or guardian. In such a situation, this form should qualify as your authorization for needed medical attention.

Authorization to Consent to Treatment of a Minor

I (we), the undersigned parent(s)/guardian(s) of the minor(s) listed below, do hereby authorize   or (family doctor)   or (adult into whose care minor(s) is entrusted) Emergency room physician in charge at: (name of children's or emergency hospital) to act in my (our) place to consent to all necessary and appropriate X-ray examinations, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under, general or special supervision of any physician or surgeon licensed to practice medicine under the laws of the state of ________ (your state). It is understood that this authorization, which is valid for 12 months from the date below, unless sooner terminated, is given in advance of any specific diagnosis, treatment or hospital care but is given to provide authority and power on the part of my (our) aforesaid(s) to give specific consent to any physician in the exercise of their best medical judgment is deemed advisable, and is in the best interest of the child(ren). Child(ren)'s Name(s) Birthdate Blood type (if known) Allergies Our address and phone number is:   Doctor's Name Phone Name Phone Medical Insurance Company or Plan Policy Number I(we) assume all financial responsibility for the delivery of such care.  date (mother and/or father)  date (mother and/or father) County of_______)                              )ss. State of ________) Subscribed and sworn to before me this ___day of _________, _________ _______________________________________ (notary public) Note: Many states require that "Power of Attorney" such as this be notarized, in which case, wait to sign this form in the presence of a notary. Even without, this form is acceptable in most states as is. Parents are advised to check with their physicans and hospitals for any changes needed, or if notarizing is needed at all. It may also be adviseable to give the family doctor or pediatrician a copy of this form once it is completed. copyright©1982 Vicki Lansky from her Dear Babysitter Handbook (Book Peddlers)