AUTHORISATION TO CONSENT TO MEDICAL TREATMENT OF CHILD
Information of Child
____________________, male, born January 16, 2017 at ____________________ and residing at ____________________, ____________________, __________, __________, ____________________.
I do not authorise ____________________ to consent to the transfusion of blood.
Name: ____________________Street Address: ____________________City, Region: ____________________, __________Postcode: __________Country: ____________________Home Phone: __________Work Phone: __________Cell Phone: __________Email: ____________________
IN WITNESS WHEREOF, I hereunto sign my name at ____________________, ____________________16th day of January, 2017.
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