AUTHORISE TO CONSENT TO MEDICAL TREATMENT OF CHILD

1. I, ____________________ of ________________________ make oath and say that I am the lawful guardian of the child listed below and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.
   

   Information of Child

   ____________________, male, born 17 April 2021 at ________________________ and residing at __________________________________________

2. I hereby authorise and appoint ____________________ of __________________________________________ as my Agent. Unless otherwise provided in this authorisation, my Agent may consent to emergency and routine medical treatment for my child, including dental treatment, anaesthesia, and blood transfusion.
   
3. My Agent may have access to any and all records, including, but not limited to, insurance records regarding any medical services or treatment provided.
   
4. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for my child. This power and authority will be effective as of the 17th day of April, 2021.
   
5. I give this consent freely and knowingly in order to provide for the child and not as a result of coercion, duress or payments by any person or agency.
   
6. This consent will remain in effect until it is revoked by notifying my child's medical, mental health care and insurance providers, in writing, and the Agent named above that I wish to revoke it.
   
7. Any questions or concerns regarding this authorisation may be directed to me at:
   

   Name: ____________________ Address: ________________________ Phone Number: ____________________ Secondary Phone: ____________________ Email: ____________________