CONSENT TO TREAT MINOR CHILDREN
Please print all information
I, _____________________________________________, parent or legal
guardian of _______________________________________________, born
________________________, do hereby consent to any medical care and
the administration of anesthesia determined by a physician to be necessary
for the welfare of my child while said child is under the care of
________________________________ and I am not reasonably available
by telephone to give consent.
This authorization is effective from _______________ to ______________.
Signature of Parent or Legal Guardian
_____________________________ ______________________________
Witness Signature Witness Name (please print)
This consent form should be taken with the child to the hospital or
physician's office when the child is taken for treatment.
This additional information will assist in treatment if it can be furnished with
the consent but is not required.
Family address _________________________________________________
Telephone: Father ______________ home ________________ work
Mother _____________ home ________________ work
Child's Birthdate ________________ Last Tetanus __________________
Allergies to drugs or foods _______________________________________
_____________________________________________________________
Special Medications, Blood Type or Pertinent Information
_____________________________________________________________
_____________________________________________________________
Child's Physician __________________________ Phone _______________
Insurance ________________________________ Policy # _____________
Preferred Hospital ______________________________________________
