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.
- Health insurance carrier:_________________
- Group no.:_____________________________
- Agreement no.________________________
- Family physician:_________________________
Child’s Allergies, if any: _____________________________________ _____________________________________________________
Date of last tetanus booster:____________
Medicines child is taking:_____________________________________________
__Mother __ Father ___Legal Guardian
Witness: ____________________________________Date: __________________
In case of emergency I can be reached at:_____________________________