Parental Consent Form
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1PARENTAL CONSENT FORM
Consent for medical treatment
DID YOU KNOW THAT, IN YOUR ABSENCE, NO ONE CARING FOR
YOUR CHILDREN CAN AUTHORIZE MEDICAL CARE WITHOUT YOUR
WRITTEN PERMISSION? If you leave your child with a sitter while you
are working or traveling, complete this form, have it witnessed and leave it
with your caregiver. This will ensure that, in an emergency, your child will
receive prompt, necessary medical care even if you are not there. The care-
giver should have this form available if a child requires medical treatment
without the parent/guardian present.
Make copies of blank form for future use.
CALL 911 IN AN EMERGENCY.
Can be used at any healthcare facility.
I (We), ______________________________________________ and ______________________________________________
(parent/guardian name)
(parent/guardian name)
of _____________________________,_____________________________,____________________________ do hereby state
(city)
(county)
(state)
that I am (we are) the parent(s) or legal guardian(s) of ________________________________________________________,
(name of child)
a minor, age ____________________, born on _______________________________________________________________,
who resides with me (us) at ______________________________________________________________________________
(street address)
_____________________________________________________________________________________________________.
(city, state, zip)
I (we) authorize ____________________________________________________________________, an adult
(name of caregiver)
over 18 years of age, who resides at __________________________________________________________ in the city of
(address of caregiver)
___________________________________________, state of ________________________, to consent to any
necessary examination, anesthesia, surgery, treatment and/or hospital care to be rendered to the above-named minor
under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in
the state(s) of __________________________________________________________________________________________
______________________________________________________________________________________________________
for the period _________________________________________ to _________________________________________
(specific date)
(specific date)
Today’s date: _________________________________________
SIGNATURE(S) OF PARENT(S) OR GUARDIAN(S):
______________________________________________________________________________________________________
Witness: ____________________________________ Witness: _____________________________________
PARENT(S)/GUARDIAN(S) CONTACT NUMBERS:
Other: _______________________________________
Cell: ________________________________________
Other: _______________________________________
Cell: ________________________________________
Child’s physician:_________________________________
Allergies (including medications):
____________________________________________________________
Phone:________________________________________
_____________________________________________________________
Chronic/existing diseases or medical problems:
MEDICAL INSURANCE
____________________________________________________________
Insurance name: _______________________________________
____________________________________________________________
Insurance phone: ______________________________________
Medications:_________________________________________________
Policyholder’s name:___________________________________
____________________________________________________________
Identification number:__________________________________
Date of last tetanus injection or booster:
Group/policy number:__________________________________
____________________________________________________________
LHN/Patient_Materials
Lutheran Hospital is owned in part by physicians.
Rev. 02/2016
#114094
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