Emergency Medical Authorization Form Page 2
Download a blank fillable Emergency Medical Authorization Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Emergency Medical Authorization Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2EMERGENCY CONTACTS
1). __________________________________________ RELATIONSHIP: _______________
HOME PHONE: _____________________
CELL PHONE: _____________________
2). __________________________________________ RELATIONSHIP: _______________
HOME PHONE: _____________________
CELL PHONE: _____________________
3). __________________________________________ RELATIONSHIP: _______________
HOME PHONE: _____________________
CELL PHONE: _____________________
PART I – TO GRANT CONSENT
I hereby give consent for the following medical care providers and local hospital to be called:
DOCTOR _______________________________
PHONE: __________________
DENTIST: ______________________________
PHONE: __________________
MEDICAL SPECIALIST: _________________________ PHONE: __________________
LOCAL HOSPITAL: ____________________________ PHONE: ___________________
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for: (1) the
administration of any treatment deemed necessary by above-names doctor, or, in the event the designated preferred practitioner is
not available, by another licensed physician or dentist, and (2) the transfer of the child to any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist,
concurring in the necessity of such surgery, are obtained prior to the performance of such surgery.
Facts concerning the child’s medical history including allergies, medications being taken, and any physical
impairments to which a physical or coach should be alerted:
______________________________________________________________________________
______________________________________________________________________________
SIGNATURE OF PARENT: _______________________________________ DATE: _______
PART II – REFUSAL TO CONSENT
I do not give my consent for emergency medical treatment of my child. In the event of illness or
injury requiring emergency treatment, instead I wish the school authorities to take the following
action: _______________________________________________________________________
______________________________________________________________________________
SIGNATURE OF PARENT: _______________________________________ DATE: ______
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business