Consent For Medical Care printable pdf download

EMERALD PEDIATRICS, INC.

CONSENT FOR MEDICAL CARE

It is best that children are brought to Emerald Pediatrics by a parent or guardian. However, there may be

times when someone else takes care of your child. That person may be a babysitter, teacher, or family

member. If your child must be brought in to Emerald Pediatrics, we need a signed consent form to

provide medical care.

This consent form allows the person you choose to seek medical treatment for your child when you are

unable to come with the child. The person you name must be 18 years of age or older.

HOW TO USE THIS CONSENT FORM

1. Complete all the information below and on page 2 of this form. Use a separate form for each

child.

2. Sign and date the form, and have an adult witness your signature. The person who will

accompany your child can be the witness of your signature.

3. Give the completed form to the person you have chosen. The person must bring the consent

form with your child to Emerald Pediatrics.

4. Be sure to tell the person coming with your child to get the doctor’s and nurse’s instructions in

writing before leaving Emerald Pediatrics. If you have questions about the instructions given,

be sure to call Emerald Pediatrics.

5. This Consent for Medical Care is good for one year. A new form must be completed and signed

every year.

I, (parent, legal guardian) _____________________________________________, cannot accompany

my child, (child’s name) _____________________________________________, to Emerald Pediatrics.

I therefore give permission to:

Name ________________________________ Relationship_________________________________

Name________________________________ Relationship ________________________________

to accompany my child.

 This person has my permission to give consent for medical treatment of my child.

 This person has my permission to sign for any immunizations that may be necessary to administer to

my child.

Date ________________

___________________________________________

______________________________________

(Signature of parent or legal guardian)

(Signature of witness-18 years of age or older)

Address ____________________________________________________________________________

Phone (Home/Cell) _____________________________

(Work) _____________________________

Consent For Medical Care