AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF CHILD
Information of Child
____________________, male, born January 30, 2015 at ____________________ and residing at ____________________, ____________________, Manitoba, __________, ____________________.
I do not authorize ____________________ to consent to the transfusion of blood.
Name: ____________________Street Address: ____________________City, Province/Territory: ____________________, ManitobaPostal Code: __________Country: ____________________Home Phone: __________Work Phone: __________Cell Phone: __________Email: ____________________
IN WITNESS WHEREOF, I hereunto sign my name this 30th day of January, 2015.
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