State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_32A > GS_32A-34

§ 32A‑34.  Statutoryform authorization to consent to health care for minor.

The use of the following formin the creation of any authorization to consent to health care for minor islawful and, when used, it shall meet the requirements and be construed inaccordance with the provisions of this Article.

"Authorization to Consent

to Health Care for Minor."

I, ____________, of____________ County, ____________, am the custodial parent having legal custodyof____________, a minor child, age______, born________, ____ .  Iauthorize____________, an adult in whose care the minor child has beenentrusted, and who resides at____________, to do any acts which may benecessary or proper to provide for the health care of the minor child,including, but not limited to, the power (i) to provide for such health care atany hospital or other institution, or the employing of any physician, dentist,nurse, or other person whose services may be needed for such health care, and(ii) to consent to and authorize any health care, including administration ofanesthesia, X‑ray examination, performance of operations, and otherprocedures by physicians, dentists, and other medical personnel except thewithholding or withdrawal of life sustaining procedures.

[Optional:  This consent shallbe effective from the date of execution to and including____________,_____].

By signing here, I indicatethat I have the understanding and capacity to communicate health care decisionsand that I am fully informed as to the contents of this document and understandthe full import of this grant of powers to the agent named herein.


Custodial Parent                                                                                             Date



On this ________ dayof__________, ____,  personally appeared before me the named_________, to meknown and known to me to be the person described in and who executed theforegoing instrument and he (or she) acknowledges that he (or she) executed thesame and being duly sworn by me, made oath that the statements in the foregoinginstrument are true.

Notary Public

My Commission Expires:

(OFFICIAL SEAL). (1993,c. 150, s. 1; 1999‑456, s. 59.)