Adult Medical Consent Form printable pdf download

Westminster Presbyterian Church

Dayton, OH

ADULT MEDICAL CONSENT FORM

Name ___________________________________ Age _______ Birth date __________

Mailing Address __________________________________________________________

Street

Address

________________________________________________________________________________________________

City

State

Zip code

Phone Numbers __________________________________________________________

E-mail address ___________________________________________________________

Social Security Number (optional) _________________

To whom it may concern:

I the undersigned do hereby willingly wish to attend and participate in the 2009

Post-High Trip to Chicago, Illinois sponsored by Westminster Presbyterian Church May

22 – 24, 2009.

The undersigned consents to any X-ray examination, anesthetic, medical, surgical

or dental diagnosis or treatment, and hospital care, to be rendered under the general or

special supervision and on the advice of any physician or dentist licensed under the

provisions of the Medical Practice Act on the medical staff of a licensed hospital,

whether such diagnosis or treatment is rendered at the office of said physicians or at said

hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses

incurred in connection with such medical and dental services rendered.

Should it be necessary for the undersigned to return home due to medical the

undersigned shall assume all transportation costs.

Hospital Insurance

____ Yes ____ No

Policy Number _______________________

Insurance Company _______________________________________________________

Emergency Contact _____________________________________ Phone __________________________

Relationship ___________________________________________

Emergency Contact _____________________________________ Phone __________________________

Relationship ___________________________________________

FORM CONTINUES

Adult Medical Consent Form