Authorization for Medical Treatment of Minors

If your child needs medical, dental or hospital services, a parent must give permission. It's the law. What about times when you cannot be reached for permission? A child may be treated without parental consent when a physician determines a true emergency exists. That means the doctor determines the child needs immediate medical care and that an attempt to obtain parental consent would result in a delay which would increase the risk to the child's life or health.

Except in a true emergency, care may be ordinarily rendered to a child only with the consent of the parent or legal guardian. Sometimes a child may need unexpected care which is not, however, a true emergency. In such cases, making an effort to contact a parent or permission can delay treatment and create unnecessary anxious moments for the child.

You can prepare for unexpected care your children might need when you are away from home. To do this, make sure babysitters know how to reach you at all times. When you know you will be hard to reach, you can give permission to other adults. They can then act for you by permitting your child to be treated if unexpected care is needed.

This is a legal document. With it you may appoint relatives, friends, teachers, clergy, neighbors- anyone who is over 18 years of age- to be responsible for your children when you are away from them. It is especially important to prepare this form for the occasions, when you know it will be hard to contact you.

Fill out this form, give it to the adult(s) you have named to act on your behalf. If your child needs unexpected medical treatment, the responsible adult(s) should present this document to the appropriate person- physician, dentist or hospital representative.



I/We, being the parent(s) or legal guardian(s) of the above named minor(s), do hereby appoint:


To act in my/our behalf in authorizing unexpected medical, dental, surgical care and hospitalization for the above named minor(s) during the period of my/our absences, from:


This document shall be presented to a physician, dentist or appropriate hospital representative at such time as unexpected medical, dental, surgical care or hospitalization may be required.



ONLINE SUBMISSION: I acknowledge that I have read and fully understand this Authorization form. I fully understand the risks and benefits of submitting personal information online. I agree that I understand the risks associated with online communications between my physician and patient, and consent to the conditions outlined herein. I agree not to hold The Professional Association for Pediatrics or any of its staff or physicians liable for network or security infractions beyond their control. Online form submission is entirely voluntary and will not impact the quality of care I receive from The Professional Association for Pediatrics should I decide against using these services. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that my physician may impose for online communications.


All articles and any forms, checklists, guidelines and. materials are for generalized information only, and should not be reviewed or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. They are intended as resources to be selectively used and always adapted – with the advice of the organization’s attorney – to meet state, local, individual organization and department needs or requirements. They are distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services.

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