AUTHORIZATION TO CONSENT
TO MEDICAL AND DENTAL TREATMENT
FOR A MINOR CHILD
We ____________ and ___________ _____________ do hereby state that we are the natural
parents/legal guardians having legal custody of:
______________________________ DOB ___________
______________________________ DOB ___________
______________________________ DOB ___________
______________________________ DOB ___________
______________________________ DOB ___________
whom reside(s) with us at: _______________________________________________________________
In the event that reasonable efforts to reach us at home, at work or on our cell phone are unsuccessful, we
do hereby unconditionally grant and authorize a faculty or staff member of Bellevue Home School
Enrichment and Tutorials in the school year 2008-2009 to consent to:
- Administration of any treatment deemed necessary by our preferred physician Dr. _____________
Phone _____________ or by our preferred dentist Dr. ______________ Phone ______________ or in the
event a preferred practitioner is unavailable, by another licensed physician or dentist when the need for
such treatment is immediate.
- The hospitalization of a minor, if in the opinion of the attending physician it is deemed essential for
his/her proper and adequate treatment. This authorization does NOT cover major surgery unless the
medical opinions of two other licensed physicians or dentist concur to the necessity for such surgery.
Information concerning the above mentioned child’s medical history, including allergies, medication being
taken and any physical impairments to which the physician should be alerted are noted on the back of the
consent.
Signatures of Parents/Guardians:
___________________________________________________________ Date:____________
___________________________________________________________ Date: ____________
TO MEDICAL AND DENTAL TREATMENT
FOR A MINOR CHILD
We ____________ and ___________ _____________ do hereby state that we are the natural
parents/legal guardians having legal custody of:
______________________________ DOB ___________
______________________________ DOB ___________
______________________________ DOB ___________
______________________________ DOB ___________
______________________________ DOB ___________
whom reside(s) with us at: _______________________________________________________________
In the event that reasonable efforts to reach us at home, at work or on our cell phone are unsuccessful, we
do hereby unconditionally grant and authorize a faculty or staff member of Bellevue Home School
Enrichment and Tutorials in the school year 2008-2009 to consent to:
- Administration of any treatment deemed necessary by our preferred physician Dr. _____________
Phone _____________ or by our preferred dentist Dr. ______________ Phone ______________ or in the
event a preferred practitioner is unavailable, by another licensed physician or dentist when the need for
such treatment is immediate.
- The hospitalization of a minor, if in the opinion of the attending physician it is deemed essential for
his/her proper and adequate treatment. This authorization does NOT cover major surgery unless the
medical opinions of two other licensed physicians or dentist concur to the necessity for such surgery.
Information concerning the above mentioned child’s medical history, including allergies, medication being
taken and any physical impairments to which the physician should be alerted are noted on the back of the
consent.
Signatures of Parents/Guardians:
___________________________________________________________ Date:____________
___________________________________________________________ Date: ____________
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