EmailMe Form - Authorization to Consent to Treatment of Minor

Name of Child
Child Date of Birth
MM / DD / YYYY
I hearby authorize and appoint the individual(s) listed below as my agents.
My agents may consent to my child's
Examination
Xrays
Medication
Procedures
Transportation by ambulence
This power and authority will be effective as of
MM / DD / YYYY
This consent will remain in effect until it is revoked by notifying the medical facility in writing.
Legal Guardian Name
Legal Guardian Phone Number
### - ### - ####
By signing this form, I make oath and say that I am the lawful guardian of the minor listed below and there are no court orders in effect that would prohibit me from conferring the power to consent upon another person. I hearby authorize and appoint the individual(s) listed above, the power and authority to consent to medical treatment for my child.
Legal Guardian Signature
Clear
For more information on Colorado Minor Consent Laws visit www.coloradohealth.org