Consent for Medical/Surgical Care/Emergency Treatment and Child’s Medical Information Form

In presenting my son/daughter for diagnosis and treatment,  I

Name: _________________________________________for _____________________________

_Mother      _Father       _Legal Guardian                                    _Son            _Daughter


of __________ years of age, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment and blood transfusions, by authorized members of the hospital staff or their designees, as may in their professional judgment be necessary.

I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition. I have read this form and certify that I understand its contents.


We/I hereby give our (my) consent to      ____________________________________________________________________________

(Name of Person/Agency)

who will be caring for our (my) child      ____________________________________________________________________________

(Name of Child)

for the period _____________________________ to _____________________________ to arrange for routine or emergency medical/dental care and treatment necessary to preserve the health of our (my) child.


We/I acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.




Telephone no.:__________________________


  • Health insurance carrier:_________________
  • Group no.:_____________________________
  • Agreement no.________________________
  • Family physician:_________________________
  • Pediatrician:____________________________
  • Surgeon:______________________________
  • Orthopedist:____________________________

Child’s Allergies, if any: _____________________________________ _____________________________________________________

Date of last tetanus  booster:____________

Medicines child is taking:_____________________________________________



Signature: ___________________________________Date:__________________

__Mother  __ Father  ___Legal Guardian

Witness: ____________________________________Date: __________________


In case of emergency I can be reached at:_____________________________