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1. Special Instructions: Additional specific instructions regarding the minor's care or treatment preferences

2. Religious or Cultural Considerations: Any religious or cultural preferences that should be considered in medical treatment

3. Insurance Information: Details of medical insurance coverage and payment responsibilities

4. Travel Authorization: Authorization for medical treatment during travel, if the document is being used for travel purposes

5. Temporary Guardian Appointment: Section appointing a temporary guardian for medical decisions, if applicable

1. Schedule A - Medical History Form: Detailed medical history form including past surgeries, vaccinations, and family medical history

2. Schedule B - Authorized Treatments List: Specific list of treatments and procedures that are pre-authorized

3. Schedule C - Emergency Contact Protocol: Detailed protocol for contacting various parties in different types of medical situations

4. Appendix 1 - Supporting Documents: Copies of relevant identity documents, power of attorney, or court orders if applicable

5. Appendix 2 - Medical Facility List: List of approved medical facilities where the authorization is intended to be used