auzziekat
03-08-2008, 05:43 PM
Consent for
Medical/Surgical Care/Emergency Treatment
and Child’s Medical Information
In presenting my son/daughter for diagnosis and treatment
Name: _________________________________________for _______________________________________
p Mother p Father p Legal Guardian p Son p Daughter
of __________ years of age, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical
treatment and blood transfusions, by authorized members of the hospital staff or their designees, as may in their professional judgment be
necessary.
I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition.
I have read this form and certify that I understand its contents.
We/I hereby give our (my) consent to __________________________________________________ __________________________
(Name of Person/Agency)
who will be caring for our (my) child __________________________________________________ __________________________
(Name of Child)
for the period _____________________________ to _____________________________ to arrange for routine or emergency medical/dental
care and treatment necessary to preserve the health of our (my) child.
We/I acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.
Name: ______________________________________ Family physician: __________________________________________
Address: ______________________________________ Pediatrician: ____________________________________________
___________________________________________ Surgeon: _______________________________________________
Telephone no.: _______________________________ Orthopedist: ____________________________________________
Name of health insurance carrier: __________________ Child’s allergies, if any: _____________________________________
___________________________________________ __________________________________________________ ______
___________________________________________ Date of last tetanus booster: _________________________________
Group no.: __________________________________ Medicines child is taking: _________________________________
Agreement no.: _______________________________ __________________________________________________ ______
Signature: __________________________________________________ _____________ Date: ___________________________
Mother, Father or Legal Guardian
Witness: __________________________________________________ ________________ Date: ___________________________
In case of emergency I can be reached at: __________________________________________________ ________________________
__________________________________________________ __________________________________________________ _____
__________________________________________________ __________________________________________________ _____
Medical/Surgical Care/Emergency Treatment
and Child’s Medical Information
In presenting my son/daughter for diagnosis and treatment
Name: _________________________________________for _______________________________________
p Mother p Father p Legal Guardian p Son p Daughter
of __________ years of age, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical
treatment and blood transfusions, by authorized members of the hospital staff or their designees, as may in their professional judgment be
necessary.
I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition.
I have read this form and certify that I understand its contents.
We/I hereby give our (my) consent to __________________________________________________ __________________________
(Name of Person/Agency)
who will be caring for our (my) child __________________________________________________ __________________________
(Name of Child)
for the period _____________________________ to _____________________________ to arrange for routine or emergency medical/dental
care and treatment necessary to preserve the health of our (my) child.
We/I acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.
Name: ______________________________________ Family physician: __________________________________________
Address: ______________________________________ Pediatrician: ____________________________________________
___________________________________________ Surgeon: _______________________________________________
Telephone no.: _______________________________ Orthopedist: ____________________________________________
Name of health insurance carrier: __________________ Child’s allergies, if any: _____________________________________
___________________________________________ __________________________________________________ ______
___________________________________________ Date of last tetanus booster: _________________________________
Group no.: __________________________________ Medicines child is taking: _________________________________
Agreement no.: _______________________________ __________________________________________________ ______
Signature: __________________________________________________ _____________ Date: ___________________________
Mother, Father or Legal Guardian
Witness: __________________________________________________ ________________ Date: ___________________________
In case of emergency I can be reached at: __________________________________________________ ________________________
__________________________________________________ __________________________________________________ _____
__________________________________________________ __________________________________________________ _____