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AUTHORIZATION FOR TEMPORARY …

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AUTHORIZATION FOR TEMPORARY GUARDIANSHIP OF MINOR. Child Full Legal Name: ________________________________________ ___________________________. Date of Birth: _______________________ Age: ___________ Gender: ___________. Doctor's Information Doctor's Name: ________________________________________ ____________________________. Doctor's Address: ________________________________________ __________________________. Doctor's Office Phone: ____________________ Doctor's Emergency Phone: ___________________. Medical Insurer/Health Plan: __________________________ Policy #: ________________________. Allergies to Medications: ________________________________________ _____________________. Allergies (Other): ________________________________________ ___________________________. If applicable, please note the conditions for which the child is currently receiving treatment: ________________________________________ ________________________________________ _.

supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in …

  Authorization, Temporary, Authorization for temporary

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