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CONSENT TO EMERGENCY MEDICAL,
DENTAL, OR SURGICAL TREATMENT FOR A MINOR CHILD
My name is __________________________. I am the mother, father, legal guardian
(print name)
(circle one)
of _____________________________________. I herby give my consent to medical treatment that is necessary to save the life
of the minor child named above.
My insurance company: _______________________________
Insurance company phone: ____________________________
Insurance policy number: ____________________________
My home address: ____________________________________
Home phone: _________________________________________
Work phone:__________________________________________
Workplace: __________________________________________
IF UNABLE TO CONTACT ME, PLEASE CALL ONE OF THE FOLLOWING:
Person Phone number
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
In case of emergency, I prefer that my child is taken to the following hospital:
_______________________________________________________________________
The child's physician is: _________________________________
Physican's phone:___________________________________________
If the above hospital or physcian is in another town from where the accident occurs, I agree that it is alright to take the child to the most convenient medical facility.
___________________________________________________________________________
(Signature of parent or legal guardian)
__________________________
(Date)
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