Form Fm S872 - Parent/guardian Consent To Medical, Dental, Or Hospital Care

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PARENT/GUARDIAN CONSENT TO
MEDICAL, DENTAL, OR HOSPITAL CARE
Child's Name (Last)
(First)
(Middle)
Date of Birth
Address
City
State
ZIP Code
Parent/Guardian Name (Last)
(First)
(Middle)
Telephone
Cell
E-Mail
I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and
hospital care under the general or special supervision and upon the advice of or to be rendered by a
physician and surgeon licensed under the Medical Practice Act for my child. This authority also
extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care
by a dentist licensed under the Dental Practice Act for my child. I further agree to pay all charges for
the dental, medical, or hospital care or treatment.
As parent or legal guardian of my child, I am responsible for the health care decisions of my
child and am authorized to consent to the services to be rendered. I represent that my consent to and
agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my child is
legally sufficient and that no consent from any other person is required by law.
Print Name of Parent/Guardian
Signature of Parent/Guardian
Date
H
S
B
CHURCH MUTUAL INSURANCE COMPANY AND
ERMES
ARGENT
ATES WISH TO POINT OUT THAT NO WARRANTY ATTACHES TO
,
,
THESE DOCUMENTS
AND IN FACT
THESE DOCUMENTS MAY NOT BE APPROPRIATE FOR THE SPECIFIC NEEDS OF A PARTICULAR
.
,
,
ENTITY
THESE DOCUMENTS ARE NOT A SUBSTITUTE FOR GOOD PRACTICE
PROPER SUPERVISION
AND DILIGENT OVERSIGHT
.
.
AND CONTROL
THERE IS NO GUARANTEE THAT THESE DOCUMENTS WILL PROTECT ANY FACILITY THAT CHOOSES TO USE THEM
,
BEFORE USING THESE DOCUMENTS OR ANY SIMILAR DOCUMENTS
YOU SHOULD CONSULT WITH YOUR OWN ATTORNEY TO MAKE
CERTAIN THAT THE DOCUMENT YOU EVENTUALLY USE IS CORRECT AND CURRENT UNDER THE LAW OF YOUR PARTICULAR
.
JURISDICTION AND THAT THE DOCUMENT MEETS YOUR NEEDS FOR YOUR PARTICULAR SITUATION
FM:S872 (8-2008) HSB

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