Consent For Medical/surgical Care/emergency Treatment And Child'S Medical Information
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1Consent for
Medical/Surgical Care/Emergency Treatment
and Child’s Medical Information
In presenting my son/daughter for diagnosis and treatment
Name: _________________________________________for _______________________________________
p Mother
p Father
p Legal Guardian
p Son
p Daughter
of __________ years of age, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical
treatment and blood transfusions, by authorized members of the hospital staff or their designees, as may in their professional judgment be
necessary.
I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition.
I have read this form and certify that I understand its contents.
We/I hereby give our (my) consent to ____________________________________________________________________________
)
(Name of Person/Agency
who will be caring for our (my) child
____________________________________________________________________________
(Name of Child)
for the period _____________________________ to _____________________________ to arrange for routine or emergency medical/dental
care and treatment necessary to preserve the health of our (my) child.
We/I acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.
Name:
______________________________________
Family physician: __________________________________________
Address: ______________________________________
Pediatrician:
____________________________________________
___________________________________________
Surgeon:
_______________________________________________
Telephone no.:
_______________________________
Orthopedist:
____________________________________________
Name of health insurance carrier: __________________
Child’s allergies, if any: _____________________________________
___________________________________________
________________________________________________________
___________________________________________
Date of last tetanus booster: _________________________________
Group no.:
__________________________________
Medicines child is taking:
_________________________________
Agreement no.: _______________________________
________________________________________________________
Signature:
_______________________________________________________________
Date: ___________________________
Mother, Father or Legal Guardian
Witness: __________________________________________________________________ Date: ___________________________
In case of emergency I can be reached at: __________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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