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Designation of Health Care Surrogate for a Minor

Designation of Health Care Surrogate for Minor

For Non-Urgent Pediatric Care — Premier Community HealthCare Group, Inc.

Child’s Information (the Principal)
Parent/Legal Guardian (Designating the Surrogate)
Designated Surrogate

I designate the following person to act as my child’s health care surrogate for non-urgent pediatric medical and dental care:

Authorization Scope
Signatures

By signing below, the parent/legal guardian authorizes the designated surrogate to consent to non-urgent pediatric care for the child named above.

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