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Emergency Consent Form to Print Out

 

If your child 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 child care provider or temporary guardian. In the event of a medical emergency, the form should accompany your child to the hospital so that medical treatment can be rendered. You may want to keep a completed form (authorizing a licensed medical doctor to give consent) in your baby's diaper bag for an extra measure of safety. Make copies of this blank form to share with a friend, and to have extras readily available.

I/We hereby authorize _________________________to give consent for all medical and/or surgical treatment that may be required for our child during our absence from___________until___________. (Consent expires one year from this date)

Child's Name:
Chronic Illnesses:
Allergies:
Current Medications:
Date of Last Tetanus Immunization:
Other:

Physician:
Telephone:
Home address of parent/guardian:
Telephone number of parent/guardian:
Additional telephone numbers:
Employer:
Telephone:
Health insurance co:
Member number:
Group number:
Nearest relative:
Telephone:
Additional relative:
Telephone:

Signed, parent/guardian:
Date:


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