Parent Authorization Form

I/We, Guardian/Father's Name and/or Guardian/Mother's Namehaving full custody of Child's Name, Ageyears old, with date of birth Month Day, Year and with primary residence at Addressdo hereby authorize medical personnel to administer the following treatments to my/our child as necessary:

• Use of Anesthesia (Local, General, or Topical): The use of anesthesia for numbing the treatment area or reducing anxiety before procedures.

• Dental Treatments (Fillings, Extractions): Necessary treatments related to oral health and dental care.

• Physical Therapy: Exercises and treatments to aid in recovery from injury or improve mobility.

• Vaccinations: Administration of necessary vaccines, as determined by healthcare providers.

• Diagnostic Imaging (X-ray, Ultrasound, MRI): Imaging procedures to diagnose internal conditions.

• Medications (Prescriptions, Over-the-Counter): Administration of necessary medications for treatment.

• Intravenous (IV) Therapy: Delivery of fluids, medications, or nutrition through the vein.

• Surgical Procedures: Surgical interventions necessary to treat specific medical conditions.

• Vision Screening and Treatments: Eye exams and corrective procedures if necessary.

• Mental Health Counseling and Therapy: Counseling sessions or therapeutic interventions for mental and emotional health.

Parental Consent

The above procedures have been explained to me/us, and I/we understand the associated risks and benefits. I/We have had the chance to ask questions, and all of them were answered and clearly explained. By signing below, I/we give permission for healthcare professionals to administer treatments to my/our child, as specified within this form.

Father Name: Date:

Mother Name: Date:

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