North Carolina Authorization To Consent To Health Care For Minor

Information you will need

• Parent Name
• County
• Minor Name
• Minor DOB
• Docket Number
• Agent Address
• Agent Name
• Notary Only: County
• Notary Only: Notary Name
• Notary Only: Parent Name
• Notary Only: Signing Day
• Notary Only: Signing Month
• Notary Only: Signing Year
• Notary Only: Notary Printed Name
• Notary Only: Commision Expiration Date
• Notary Only: Principal Identification

Completed by the principal.

The form includes a notary acknowledgment.