CONCENT TO TREAT MINOR CHILD

(Please fill one form for each child)

 I, ________________________________, parent or legal guardian of___________________________, 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 our care giver whose legal name is: ________________________________, and only in an emergency event that I am NOT reasonably available by telephone to give consent. 

This authorization is effective from _______________ to ________________. 

Name (please print)   ________________________________________________________________

Signature of Parent or Legal Guardian: _________________________________________________ 

Witness name: ______________________________________________________________________

Signature Witness:    ___________________________________ _____________________________

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 numbers:

Father   _______________________ home ________________________ work

Mother _______________________ home ________________________ work

Child's Birthdate __________________

Last Tetanus immunization date:  __________________

Allergies to drugs or foods ______________________________________________________________________________________________________________________ 

Special Medications, Blood Type or Pertinent Information ______________________________________________________________________________________________________________________ 

Child's Physician: _____________________________________ Phone number:  _____________

Insurance name: _____________________________________ Policy number:    _____________

Preferred Hospital _______________________________________________________________