Medical Consent Form - Kapi'Olani Community College printable pdf download

Student’s Name: ______________________________

UH ID#: ______________________________

Program:______________________________

UNIVERSITY OF HAWAI'I • KAPI'OLANI COMMUNITY COLLEGE

Nursing Department

MEDICAL CONSENT FORM

(To be completed by student or parent if a minor)

Please Fill out either A OR B:

I (We)

consent to and

(student or parents/guardian if a minor)

authorize any medical doctor or dentist and others working under their supervision to treat

___________________ for any illness or injury.

(name of participant)

I (We) further agree to pay any and all such dental and medical costs, expenses, and charges and to release

and discharge and hold harmless the State of Hawai‘i, its employees and agents from and against any liability

or any claim or demand arising from or connected with such medical treatment or care.

***********OR*********

I (We)

, DO NOT consent to

(student or parents/guardian if minor)

or authorize any medical doctor or dentist or others working under their supervision

to treat

________________ for any illness or injury.

(name of participant)

I (We) therefore agree to assume the risk of any injury or damages relating to, and outside of or in connection

with said failure to provide any medical treatment or care.

I (We) therefore agree to assume the risk of any injury or damages to

____________ from the lack of any medical care or treatment

(name of participant)

and further agree to release and discharge and hold harmless the State of Hawai‘i, its employees and agents

from and against any liability and any claim or demand arising out of or in connection with said failure to

provide any medical care and treatment.

Student's Signature

Date

Co-signature of parent or guardian if a minor

Date

Home Address

Phone (Home)

City

Zip Code

Phone (Business)

IN CASE OF EMERGENCY NOTIFY: Please Give at least two names:

First

Phone

Second

Phone

Third

Phone

Give name of physician. If you don’t know, write "NA".

PHYSICIAN'S FULL NAME

Phone _____________________________

Are you under treatment for any condition or taking any medications we should know about? Please specify.

Rev.01/2013

Medical Consent Form - Kapi'Olani Community College

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