COMPLETE EITHER PART I OR PART Il
PART I - CONSENT FOR TREATMENT PART I - CONSENT In the
event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the named doctor, or in the event the designated practitioner is unavailable, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained to the performance of such surgery. I hereby give consent for the following medical care providers and local hospitals to be called: