Parental Emergency Medical Consent Form
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2PARENTAL EMERGENCY MEDICAL CONSENT
This form must be presented upon admission for treatment.
Child’s Full Name ___________________________________________ Date of Birth _________________
In the event that my child (listed above) may require medical and/or surgical care while I am out of the city or
unable to be reached, I hereby give my consent to medical and/or surgical treatment to the
___________________Hospital and Doctor ______________or his/her designee to provide this care. In the
event that my child (listed above) may require dental and/or dental surgical care while I am out of the city or
unable to be reached, I hereby give my consent for dental and/or dental surgical care to
___________________Hospital and Doctor ______________ or his/her designee to provide this care. I
agree to pay the entire costs and fees contingent on any emergency medical care and/or treatment for my
child as secured or authorized under this consent. COMMENT: Every effort will be made to notify
parents/guardians immediately in case of emergency. This form will be presented upon admission for
treatment.
1.
Parents/Guardians/Custodians with whom the child resides.
Name _________________________________________Relationship to Child _______________________
Address___________________________________________________ Home Phone _________________
Employer________________________________________________ Work Phone ___________________
Cell Phone ___________________ Email Address ____________________________________________
Name _________________________________________Relationship to Child _______________________
Address___________________________________________________ Home Phone _________________
Employer_________________________________________________ Work Phone __________________
Cell Phone ___________________ Email Address ____________________________________________
2.
Persons to contact in case of emergency if parents are unavailable and who are authorized
to pick up the child.
Name _________________________________________Relationship to Child _______________________
Address___________________________________________________ Home Phone _________________
Employer_________________________________________________ Work Phone __________________
Cell Phone ___________________
Name _________________________________________Relationship to Child _______________________
Address___________________________________________________ Home Phone _________________
Employer_________________________________________________ Work Phone __________________
Cell Phone ___________________
3.
Are there custody or restraining orders for person(s) who may attempt to pick up or have
contact with the child while in care at the center? ______
Name _________________________________________Relationship to Child _______________________
Name _________________________________________Relationship to Child _______________________
4.
Child’s Information
Child’s Doctor ________________________ Phone #___________ Address_________________________
Child’s or Family Dentist ________________ Phone #___________ Address_________________________
Date of Last Tetanus ___________ Known Allergies ____________________________________________
Present Medications _______________________________Religious Preference (Optional)_____________
Insurance Company________________________________ Policy Holder’s I.D.______________________
This consent will be in effect for one year and continue while the child is enrolled in this facility.
_______________________________________
___________________________________________
Signature of Parent/Guardian
Date
Signature of Parent/Guardian
Date
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