Authorization to Treat a Minor Form (Form B)
CENTAURUS HIGH SCHOOL BANDS, 2018-2019

I (we) the undersigned parent(s) or legal guardian(s) of the undersigned student do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or specific supervision of any member of the medical staff and emergency staff licensed under the provisions of the Medical Practice Act or a dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the Colorado Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospitalization being required but is given to provide authority and power to render care which the aforementioned physician, it the exercise of his or her best judgment, may deem advisable. It is understood that the effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.

Student First Name *
Your answer
Student Last Name *
Your answer
We may administer Tylenol/Advil if requested by the student? *
List ANY special health conditions your student has or has had in the past. *
Your answer
List ANY medications your student currently takes and reasons *
(include insulin, anti-convulsive, antihistamine and tranquilizers)
Your answer
Family Physician *
Your answer
Family Physician Phone Number *
Your answer
List all allergies to drugs or foods. *
Your answer
Insurance Provider *
Your answer
Insurance Group Number *
Your answer
Insurance Policy Number *
Your answer
Parent (or guardian) Electronic Signature *
By typing your name in the box below you acknowledge that you are giving permission to treat your student to the above specifications.
Your answer
Date *
Your answer
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