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


               Children Age 18 & Older:


Authroization for Another Person to Consent to Medical Treatment


          Telephone Number:  


          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. 



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Shalom Health Care Center

Signature Certificate
Document name: Consent for Minors and ROI
lock iconUnique Document ID: 89f2d10f1707de450c78404460994856840f10d7

Timestamp Audit
May 7, 2020 9:42 am EDT Consent for Minors and ROI Uploaded by Darren Huff – [email protected] IP