Medical Consent Form

MEDICAL CONSENT AND AUTHORIZATION FORM

Resident Name:

DOB:

I hereby consent and authorize: Bay County Juvenile Home

520 West Hampton Road, Essexville, MI 48732

Phone: 989-892-4519 Fax: 989-892-4419

To provide the following services for my child:

Routine, nonsurgical medical care, or emergency medical and surgical treatment of the minor child. Including consent for hospital admittance, emergency treatment including surgery, dental care or mental health services. All services shall be provided by qualified medical personnel as deemed necessary to protect the health and well being of my child. This consent and authorization includes the authorization for disclosure of my child’s complete health records as may be necessary to provided appropriate medical care and treatment and follow-up care. Initial

It is understood that the Bay County Juvenile Home will make all reasonable efforts to notify me of any injury or emergency medical care or treatment that is necessary while my child is in the care and custody of the Bay County Juvenile Home. I understand I have the right to revoke this authorization at any time prior to disclosure by giving written notice to the Facility Director. Initial

I consent to testing for infectious, contagious and sexually transmitted diseases including, but not limited to hepatitis, hepatitis B, HIV and AIDS in the event my child’s bodily fluid comes into contact with any volunteer, employee or resident of the BCJH. Results of that testing will be made available to the Director of the Bay County Juvenile Home. Initial

Last date dental appointment for youth:

Last date youth youth had a physical:

ls youth up to date on immunizations?:

Medication Allergies: Include reaction if ingested or exposed to medication. What precautions are required by medical professional?

Food Allergies: Include reaction if ingested or exposed to food. What precautions are required by medical professional? If your youth has an intolerance to food please note that it is an intolerance versus an allergy.

Other Allergies: Include reaction if ingested or exposed to item. What precautions are required by medical professional? .

Does youth have prescribed medications for allergic reactions such as an EpiPen or other prescription?

Did you bring this prescription to the facility to be available for the youth in the event of an allergic reaction?

Has this youth ever been diagnosed with Asthma?

Does youth currently have prescribed inhaler?

If yes will inhaler be provided to this facility while the youth is lodged?

Will the youth have trouble breathing participating in physical activity without an inhaler? indoor/outdoors

Does youth have prescription glasses?

Are those glasses available to the youth in facility while lodged?

Parent Email

example@example.com

Parent/Guardian Signature:

Printed Name:

Date:

Date

Medical Insurance Information:

520 West Hampton Road, Essexville, Michigan 48732 Tel: (989) 892-4519| Fax: (989) 892-4419 | TDD (hearing impaired): 989-895-4049 Web: www.baycounty-mi.gov