Authorization for Consent to Medical Treatment of Minor Child - Free Download
4.3,
3247
votes
Please vote for this template if it helps you.
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 authorize _____________________________________________________________ to 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
): ___________________________________________
Telephone: _______________________________ Cell: _____________________________
Primary Medical Insurance Carrier _____________________________________________________
Member’s Name ___________________________________________________________________
ID# _______________________________ Group # ____________________________
Signature of parent/guardian(s) ________________________________________________________
