T.C.
Hi Lily --
Here is the language from the authorization we use whenever we travel. We got this from our doctor, so we're pretty comfortable with the language. One other thing to remember when you travel is to always leave a copy of your insurance and prescription cards in case your caregivers are challenged.
We, the undersigned parents of ___________________, a minor, do hearby authorize _______________________ as agent(s) for the undersigned to consent to an x-ray examination, and anesthetic, medical, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and 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 to power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which a physician, meeting the requirements of this authorization, may in the exercise of his/her best judgment deem advisable.
We hereby authorize any hospital which has provided treatment to the above named minor to surrender physical custody of such minor to my/or above named agent(s) upon the completion of treatment.
These authorizations shall remain effective until _______, unless sooner revoked in writing delivered to said agent(s).
I hope this helps.
T.
