Russell W. Hall & Associates, a Professional Corporation, Attorneys at Law - Authorization to Consent to Treatment of Minor

Sending the kids away for spring break? What if one needs a doctor or dentist? Will the child get treatment if no parent is there?

Except for emergencies, a parent's consent is generally mandatory: no consent, no treatment. However, if no parent can be contacted, a grandparent, adult brother or sister, or adult aunt or uncle may consent. Parents may also delegate authority to consent, even for non-emergencies, to the child's school, or to any other adult.

This form protects both the designated adult and the attending physician or dentist from second-guessing, by immunizing them for all but negligence. In other words, they can make a different decision than an absent parent, just not a stupid decision.

The form is specific to Texas, and may or may not be honored elsewhere, e.g., on a Colorado ski trip. Also, it never hurts to ask your doctor or dentist if they have their own form.

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Authorization to Consent to Treatment of Minor

© 2004 State Bar of Texas. Reprinted by permission. Neither the State Bar of Texas nor any department, section, officer, volunteer committee, employee, or member of the State Bar of Texas makes either express or implied warranties in regard to the use of this form and shall not be held liable for any losses caused by reliance on the accuracy, reliability or timeliness of such information. Each attorney must depend on his or her own knowledge of the law and expertise in using or modifying the form. Practitioners should remember that forms should always be considered merely an optional starting place for a legal matter. This form is not intended to be and does not constitute legal advice, and no attorney-client relationship is established. Members of the public should remember that a form is no comparison or substitute for an attorney's legal advice. If you have a legal question or problem, the State Bar of Texas strongly encourages you to consult with an attorney licensed in good standing in your jurisdiction.

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Authorization to Consent to Treatment of Minor

I, ________________________ [name], am the [parent/guardian/managing conservator] of ________________________ [name of minor], a minor child, and have the power to consent to medical treatment for [him/her]. [Include if applicable: ________________________ [Name[s]] [is/are] ________________________ [name of minor]'s [other parent/parents].] I authorize and appoint ________________________ [name] as my agent to consent to medical treatment of the minor when I cannot be contacted to so consent, such medical treatment to include, without limitation, X-ray examination; anesthetic treatment; medical, dental, or surgical examination or treatment; and general hospital care. No prior determination of life-threatening emergency or danger of serious or permanent injury resulting from delay of treatment need be made under this authorization.

I will indemnify and hold harmless from any expense or claim of any nature any entity that provides or causes to be provided examination, treatment, or hospital care under this authorization (except to the extent such entity is negligent therein) and conditionally agree to make or cause to be made, by assignment of third-party benefits or otherwise, full and complete payment for such examination, treatment, or hospital care.

SIGNED on ________________________ [date].

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[Name of parent/guardian/managing conservator]

Child's name: _____________________________________________________________

Birth date: _______________________________________________________________

Last tetanus immunization: ________________________________________________

Allergies: ________________________________________________________________

Hospitalization insurance co.: ____________________________________________

Pediatrician: _____________________________________________________________

Type of credit card: ______________________________________________________

Credit card number:________________________________________________________

Name on credit card: ______________________________________________________

Expiration date: __________________________________________________________