Medical Treatment Authorization And Consent - Arts Of The Pamlico printable pdf download

Medical Treatment Authorization And Consent - Arts Of The Pamlico

Medical Treatment Authorization and Consent

I,_______________, being the __________ of ______________ authorize Arts

of the Pamlico (AOP) to seek, obtain and consent to routine medical care and

treatment, emergency medical care and treatment, dental care and treatment, for

______________as deemed necessary by a licensed medical or healthcare

professional. This authorization is for the time period when my child is in the care

of AOP, and is effective until revoked by me.

Child's Information

Child’s Full Name: _____________________________

Address: _____________________________________________

Date of Birth: __________

Age: __________

Parent/Authorized Adult

Parent’s/Authorized Adult Name 1: ________________

Address: ______________________________________________

Phone Number (Home): __________________

Phone Number (Cell): __________________

Parent’s/Authorized Adult Name 2: __________

Address: _______________________________________________

Phone Number (Home): _______________________

Phone Number (Cell): _______________________

Emergency Contact Person’s Information

Emergency Contact's Full Name: _____________________________

Address: ______________________________________________

Phone Number (Home): _______________________

Phone Number (Cell): _______________________

Child’s Health Information

Health Conditions (e.g. Asthma, Diabetes):

________________________________________________________________

Allergies (e.g. to Medications and Food if none, please write none):

________________________________________________________________

Child Medical Consent (Rev. 1337B55)

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Medical Treatment Authorization And Consent - Arts Of The Pamlico