Emergency Medical Consent Form
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1EMERGENCY MEDICAL CONSENT
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 for 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 surgical care to ______________Hospital and Doctor _____________or his/her designee to provide this care. In
the event the above doctor, dentist, or hospital are not available or in close proximity when care is needed, I give
permission for Children's Center to authorize medical or dental care at the nearest medical facility. I agree to pay all 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/Guardian/Custodians with whom the child resides:
Name__________________________Address_________________________Home Phone ______________________
___Relationship to child: ___________________
Work Phone_______________________ Cell Phone__________________
2. Parents/Guardian/Custodians with whom the child resides:
Name__________________________Address_________________________Home Phone ______________________
Relationship to child: ____________________
Work Phone_______________________ Cell Phone____________________
3. Persons to contact in case of emergency if parents are unavailable (individual is authorized to pick up child):
Name___________________ Home Phone ___________
Relationship to child: ___________
Cell Phone_____________
4. Persons to contact in case of emergency if parents are unavailable (individual is authorized to pick up child):
Name___________________ Home Phone ___________
Relationship to child: ___________
Cell Phone_____________
5. Is there any custody or restraining orders for persons who may attempt to pick up or have contact with the child while
in care at the center?
Name___________________________________________________________________________________________
6. Health Information:
Child's Doctor_____________________Address:_________________ City________State_____Phone_____________
Child's Dentist_____________________Address:_________________ City________State_____Phone_____________
Allergies: ________________________________________________________________________________________
Date of Last Tetanus Shot: ___________________ Present Medications ______________________________________
Insurance Company________________________________________Policy Holder's I.D. ________________________
_______________________________________
_________________________________________________
Signature of Parent/Guardian
Date
Signature of Parent/Guardian
Date
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