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Medical Consent

Anonymous started this conversation

My daughter is going to South Carolina for 10 days and I knew she needed a medical consent form, just in case ( I HOPE NOT!!!)

After working in the ER, I came across a LOT of kids who needed treatment but: were not with their parents, had no consent, or were old enough,but did not know their insurance information. Not only that, but when you take your child to the ER the last thing you are thinking about is your insurance card or what are they allergic to, when was their last tetanus shot? 

So for all the parents out there, take a few minutes, copy and paste the form into Word and fill it out ( just in case). Be sure to include a copy of your insurance cards ( front and back) to keep and save precious time.  

 ****************************************************************

 

Parental Consent for Medical Treatment

Child’s Information

Name: _______________________________________________________________

DOB:_________________________________________________________________

Address_______________________________________________________________

Home phone # ___________________________________________________________

 

Parent information:

Name: _______________________________________________________________

Address_______________________________________________________________

# where parents can be reached:_________________________________________________

                                                                       

Caregiver Information:

Name: _______________________________________________________________

Address_______________________________________________________________

# where caregiver can be reached:___________________________________________

 

The above named caregiver shall be authorized to consent for all medical and/or surgical treatment and/or other medical procedures (including administration of anesthesia, blood transfusions, diagnostic tests, mental health services,  etc.), for the above named child, which may be required during my absence. If circumstances permit, I would like to have our doctor consulted in connection with such treatment.

 

This consent serves as permission for treatment by ANY Hospital, emergency room, or medical personnel.

 

I agree to pay for all services provided to my child in my absence.

 

This authorization shall be effective until:  (DATE) , unless earlier revoked by me.

 

Signatures

_______________________________________________________

Parent/ Date

_______________________________________________________

Witness/ Date

 

Family Physician Information    

Name: _______________________________________________________________

Address_______________________________________________________________

# where Doctor can be reached:_________________________________________________

 

Insurance Information

Company name ___________________________________________________

ID # ____________________________________________________________

Group # __________________________________________________________

Phone #  _________________________________________________________

Other insurance information: __________________________________________

_________________________________________________________________

___________________________________________________________________

 

Medical Information

Chronic or existing medical conditions:  ____________________________________

_________________________________________________________________

___________________________________________________________________

 

Current Medications:

_________________________________________________________________

___________________________________________________________________

 

Known Allergies

_________________________________________________________________

___________________________________________________________________

 

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StarsMom
Thank you so much! We are leaving our 15 month old daughter for the first time with my in-laws and although I know she will be well taken care of, kids will be kids and sometimes accidents do happen or a child could get sick suddenly. Thank you again for sharing this with the public =)
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myrab51
Thanks! I occasionally need to travel out of state on business. I have two kids with asthma that I leave with their grandparents when I go. I try to print them up a fresh form every year.
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It'sMe

THANK YOU!!

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