Form Fm S812 - Authorization For Medical Treatment (Page 2 of 2) in pdf

Form Fm S812 - Authorization For Medical Treatment Page 2

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care

being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in

the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.

Dated:

, 2

Additional Information:

(SIGNATURE OF PARENT OR GUARDIAN)

Additional Information:

Parent/Guardian

Address

City

State

ZIP Code

Home Phone No.

Work Phone No.

Medical/Health Insurance Company

Insurance Policy No.

In case of emergency, notify

Relationship to Minor

Emergency Phone No.

Allergies/Allergic reactions of my child

Medicine being taken by my child

Other information regarding my child's health that a doctor should know

THIS FORM WAS RESEARCHED AND DRAFTED BY THE LAW FIRM OF:

MCKAY BYRNE & GRAHAM

3250 WILSHIRE BLVD STE 603

LOS ANGELES CA 90010-1578

(213) 386-6900

IT IS MADE AVAILABLE AS A SAMPLE FORM WITH THEIR PERMISSION. NEITHER MCKAY, BRYNE & GRAHAM NOR CHURCH

MUTUAL INSURANCE COMPANY WARRANT THAT IT IS APPROPRIATE FOR USE BY ANY OF OUR INSUREDS. THE FORM WAS

DRAFTED AS A SAMPLE DOCUMENT AND MAY NOT BE APPROPRIATE FOR THE SPECIFIC NEEDS OF A PARTICULAR

ORGANIZATION. THIS FORM IS NOT A SUBSTITUTE FOR GOOD PRACTICE, PROPER SUPERVISION, AND REPAIR. THERE IS NO

GUARANTEE THAT THIS FORM WILL PROTECT ANY FACILITY THAT CHOOSES TO USE IT. BEFORE USING THIS SAMPLE

DOCUMENT OR ANY DOCUMENT LIKE IT, 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.

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FM:S812 (4-2004) MBG

Form Fm S812 - Authorization For Medical Treatment Page 2