Emergency Medical Consent Form
Download the document to the computer for easy use
There are more pages to preview,Read on

EMERGENCY MEDICAL CONSENT FORM

_________________________________________________ has my permission to obtain
emergency medical treatment for my child, ________________________________________
when I cannot be reached or if a delay in reaching my child would be dangerous for him/her.
Mother/Guardian’s Name _____________________________________________________
Home Phone _________________________

Cell Phone _________________________

E-mail Address: ______________________________________________________________
Father/Guardian’s Name______________________________________________________
Home Phone _________________________

Cell Phone _________________________

E-mail Address: ______________________________________________________________

My insurance provider is _______________________________________________________
My child’s medical record number is _____________________________________________
Preferred hospital/treatment center ______________________________________________
My c