Medical Consent Form - Downingtown Area Schools printable pdf download

Medical Consent Form - Downingtown Area Schools

DOWNINGTOWN AREA SCHOOLS

Phone numbers where parents can be reached:

MEDICAL CONSENT FORM

Office:

Home:

ATHLETE:

Other:

Permission is hereby granted to the attending physician to

proceed with any medical or minor surgical treatment, X-

Name of Family Physician:

ray examinations and immunizations for the above-

named student. In the event of serious illness, the need

Physician Phone Number:

for major surgery or significant accidental injury, I

understand that an attempt will be made by the attending

Hospital Preference:

physician to contact me in the most expeditious way

possible. If said physician is not able to communicate

Emergency contact if parent cannot be reached:

with me, the treatment necessary for the best interest of

the above-named student may be given.

Name

Phone

In the event that an emergency arises during a practice

Medic-Alert History:

session, an effort will be made to contact the parents or

guardians as soon as possible. Permission is also granted

to the athletic trainer to provide the needed emergency

treatment of the athlete prior to his admission to the

medical facilities.

Insurance Carrier:

Insurance Number:

SIGNATURE OF PARENT/GUARDIAN

DATE

Medical Consent Form - Downingtown Area Schools