Authorization to Consent to Treatment of a Minor

Temple Beth El
Jews in the Wilderness
2023-2024/ 5784

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Please complete a separate Treatment Consent  form for each child you are registering in Jews in the Wilderness.
All items with a red * are required.  When done, click on "Submit" at the bottom.


 
Authorization to Consent to Treatment of a Minor
 
{I) {we) the undersigned parents/guardians of the minor named below, do hereby authorize Temple Beth El as agents for the undersigned to consent to any X-Ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgement may deem advisable.

This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. (I) (we) hereby authorize any hospital which has provided treatment to the below-named minor pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender physical custody of such minor to (my) (our) above named agent(s) upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California.

These authorizations shall remain effective until 6/30/2023 unless sooner revoked in writing delivered to said agent(s).

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