Children’s Emergency Consent Form

If your child/children needs emergency medical care and you aren’t available to give
formal consent to medical authorities, care may be unnecessarily delayed.
To protect your child, leave a completed Emergency Consent Form with your babysitter, day care center or temporary guardian.
In the event of a medical emergency, the form should accompany your child to the
hospital.

I/We hereby authorize______________________________________________________________
to give
consent for all medical and/or surgical treatment that may be required for our
child/children during our
absence from (date)_________ until (date)_____________.

Child #1: Full Name-_____________________________ Date of Birth-____________
Social Security #-_________________ Medical Record #__________________________
Chronic Illnesses________________________________________________________________________
Allergies-________________________________________________________________
Current Medications-______________________________________________________
Date of Last Tetanus Immunization-_____________________

Child #2: Full Name-_____________________________ Date of Birth-____________
Social Security #-_________________ Medical Record #__________________________
Chronic Illnesses________________________________________________________________________
Allergies-________________________________________________________________
Current Medications-______________________________________________________
Date of Last Tetanus Immunization-_____________________

Child #3: Full Name-_____________________________ Date of Birth-____________
Social Security #-_________________ Medical Record #__________________________
Chronic Illnesses________________________________________________________________________
Allergies-________________________________________________________________
Current Medications-______________________________________________________
Date of Last Tetanus Immunization-_____________________

Child #4: Full Name-_____________________________ Date of Birth-____________
Social Security #-_________________ Medical Record #__________________________
Chronic Illnesses________________________________________________________________________
Allergies-________________________________________________________________
Current Medications-______________________________________________________
Date of Last Tetanus Immunization-_____________________

Family Physician/Pediatrician: _________________________ Telephone
#_________________________
Names of Parents/ Legal
Guardian(s)________________________________________________________
Home address of parent/legal
guardian:______________________________________________________
Telephone #’s of parent/legal
guardian:______________________________________________________
Employer: ________________________________ Telephone
#__________________________________
Health Insurance Co._______________________ Member #__________________ Group
#___________
Policy Holder Name: ________________________ Policy Holder Date of Birth:
___________________
Emergency Contact (other than
parent/guardian)_______________________________________________

Telephone#___________________________
Signed: Parent/Legal Guardian________________________________ Date: ______________

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