Medical And Dental Consent printable pdf download

MEDICAL AND DENTAL CONSENT

My Child, _______________________________ DOB: _____________ is placed in

foster/kinship care with Children’s Choice. In accordance with my child’s placement and to

enable the employees and the foster/kinship parents of Children’s Choice to provide my child

with the best care possible, I give my consent to (a) the social workers, the supervisors, and other

representatives of Children’s Choice and my child’s foster/kinship parent(s) to arrange for and

(b) appropriate hospitals, clinics, medical and dental personnel to perform medical and/or dental

treatment upon my child in accordance with this consent form.

All routine pediatric medical and dental care appropriate for a child of my child’s

age and condition, including but not limited to medical and/or dental

examinations, diagnostic testing, x-rays, immunizations, vaccinations, TB testing,

vision and hearing tests, blood and urinalysis tests incident to or part of routine

pediatric care, administration of medication, and all other procedures and

treatments in the regular course of providing medical or dental care for my child.

Recognizing that circumstances may prevent my being informed in advance if my

child requires emergency medical or dental treatment, I further give my consent to

preserve my child’s life, prevent permanent impairment of his/her health or

normal functioning, to alleviate severe pain, or in any other circumstance which

emergency medical or dental treatment is warranted.

Revocation

I understand that I have the right to revoke this authorization, in writing, at any time by sending

written notification to Children’s Choice at _________________________________________

_______________________________________ . I further understand that a revocation of this

authorization is not effective to the extent that the action has been taken in reliance on the

authorization.

Expiration

Unless sooner revoked, this consent expires 1 (one) year from the date signed.

Signature of Parent/Guardian

(Date)

Signature of Parent/Guardian

(Date)

Signature of Witness

(Date)

To Be Completed by the Birth Parent(s)or if the County has full custody, by the County Worker

CC 2:8A

Rev. 11/06

Medical And Dental Consent