Consent for Minors and ROI


    Patient Consent for Treatment of Minors and/or Release of Information to Others

    Patient Name:

    Date of Birth: //

    Parent/Legal Guardian:

    Release of Information to Other Persons

                   Spouse:        

                   Children Age 18 & Older:

                   Other:

    Authroization for Another Person to Consent to Medical Treatment

              Name:  

              Telephone Number:  

              Address:  

              City:      State:       Zip Code:

              to consent, in my absence, for all medical treatment and/or medical procedures. Shalom Health Care Center may rely upon this consent with the same force and effect as if personally executed by me. 

     

    All decisions indicated above will remain in effect until terminated by me in writing. 

     

     

    Leave this empty:

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    Shalom Health Care Center https://www.shalomhealthcenter.org
    Signature Certificate
    Document name: Consent for Minors and ROI
    lock iconUnique Document ID: 89f2d10f1707de450c78404460994856840f10d7
    Timestamp Audit
    May 7, 2020 9:42 am EDTConsent for Minors and ROI Uploaded by Darren Huff - [email protected] IP 12.35.168.178