Authorization To Consent To Treatment Of Minor Form (Page 2 of 2) in pdf

Authorization To Consent To Treatment Of Minor Form Page 2

Emergency Information

IN CASE OF EMERGENCY NOTIFY: _________________________________

Address ________________________ City _____________State___ Zip __________

Phone: Home (____) __________ Work (____) _________ Cell (____) __________

IF DIFFERENT THAN ABOVE COMPLETE:

Father’s Name __________________________________________________________

Address ________________________ City _____________State___ Zip __________

Phone: Home (____) __________ Work (____) _________ Cell (____) __________

Mother’s Name _________________________________________________________

Address ________________________ City _____________State___ Zip __________

Phone: Home (____) __________ Work (____) _________ Cell (____) __________

MINOR’S PHYSICIAN

Name _______________________________________________________________

Address ________________________ City _____________State___ Zip __________

Telephone Number

(_____) _____________________

Name of Medical Insurance Provider*_______________________________________

Policy # _____________________________ Expiration Date ___________________

*Attach a copy of your medical card

If your son or daughter has a medical problem or is taking medication that would be

important for us to be aware of, please indicate here:____________________________

________________________________________________________________________

3/7/08

Authorization To Consent To Treatment Of Minor Form Page 2