CONSENT FOR CHILD'S NECESSARY OR UNEXPECTED OR EMERGENCY MEDICAL
AND DENTAL HEALTH OR HOSPITAL SERVICES
I, ___________________________, parent and legal guardian of
_____________________________
(name of
parent or guardian) (name
of child)
born, _____________, hereby authorize
_____________________________ or any person or agency
(name
of agency)
acting as the agent of _____________________________________
and give my consent for necessary or unexpected or emergency medical or dental health
and/or hospital services for the card of my child.
This consent and authorization is valid for the above named
minor during the period from
_______________________ to ______________________________.
This document shall be presented to a physician, dentist of
appropriate hospital representative at such time as necessary, unexpected or
emergency medical or dental health or hospital services may be required.
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CHILD'S FULL NAME |
DATE OF BIRTH |
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SIGNATURE |
RELATIONSHIP |
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WITNESS |
DATE |
The following are necessary medical or dental health of
hospital services (For example: medication, allergy shots - this does not
exclude emergency medical treatment as authorized above), which
_____________________________________ is authorized to
perform or obtain:
(name
of agency)
1. __________________________________________
2. __________________________________________
3. __________________________________________
It is understood that
____________________________________________ will contact the parent/guardian
(name
of agency)
immediately to inform them of the child's condition and of
all emergency or unexpected medical, dental, health or hospital services. If it is possible and will not cause any
deterioration or worsening of undue risk or pain to my child, all surgical
proceedings shall be at notice to me.
The following is the hospitalization coverage for my child
_________________________________________
(name
of insurance company)
___________________________________ and my child's family
physician ___________________________
Physicians phone
__________________________________________________________________________
The following information will also help to expedite the care:
PAST HEALTH PROBLEMS:
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ALLERGIES: (also include allergies to drugs)
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CURRENT MEDICINES:
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DATE OF LAST TETANUS IMMUNIZATION:
_________________________________________________