Consent For Emergency Medical Treatment
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Adult and Elderly Residential Facilities
AS THE CLIENT, AUTHORIZED REPRESENTATIVE OR CONSERVATOR, I HEREBY GIVE CONSENT TO
_________________________________________ TO PROVIDE ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________ . THIS CARE MAY BE GIVEN UNDER WHATEVER
NAME
CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE INDIVIDUAL NAMED
ABOVE.
CLIENT HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE
CLIENT/AUTHORIZED REPRESENTATIVE/CONSERVATOR SIGNATURE
(CIRCLE APPROPRIATE TITLE)
HOME ADDRESS
HOME PHONE
WORK PHONE
(
)
(
)
LIC 627C (ENG/SP) (4/00) (CONFIDENTIAL)
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Parent category: Legal