Medical Treatment Authorization Letter (Free Sample)
Use this sample medical treatment authorization letter as a template for your medical treatment authorization letter.
Last updated on September 19th, 2021
Medical Treatment Authorization Letter Sample
Name of Legal Guardian
Address of Legal Guardian
City, State, Zip Code
RE: Medical Treatment Authorization
To Whom It May Concern:
I, Name of Legal Guardian, am the lawful guardian of the female child named below. I give permission and consent to Name, Address and Phone Number of Temporary Caregiver to authorize medical treatment for Full Name of Child and date of birth. This permission is granted from DATE and will expire on DATE.
Signature Of Legal Guardian DATE
Printed Name of Legal Guardian
Signature of Witness or Notary (if required by the state) DATE
Printed Name of Witness
By Andre Bradley