Authorization For Consent To Medical Treatment Of Minor Child Preview
hAuthorization for Consent to Medical Treatment of Minor Child
Authorization for Consent to Medical Treatment of Minor Child
If your child needs emergency medical care and you aren’t available to give formal consent to medical authorities, care may be unnecessarily delayed. To protect your child, leave a completed EMERGENCY CONSENT FORM with your baby-sitter, day care center or temporary guardian. In the event of a medical emergency, the form should accompany your child to the hospital.
I/we hereby authorizeto give consent for all medical and/or surgical treatment that may be required for our child during our absence.
Child’s Full Name
Date of birth
Child’s Physician: Child’s Allergies Medications child is taking: Important medical history Date of last Tetanus Immunization
Home address of parent/guardian:
Parent/guardian Telephone # : Cell #
Emergency contact (other than parent/guardian):
Primary Medical Insurance Carrier
ID# Group #
Signature of parent/guardian(s)
Signature of adult witness
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