Authorization for Emergency Medical Treatment Form

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Hopeful Hearts staff or volunteers to:

1. Secure and retain medical treatment and transportation if needed.

2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Consent Plan

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.
Date

MonthDayYear
Date
Consent Signature (Client, Parent or Legal Guardian)

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Non-Consent Plan

I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/ aid is required, I wish the following procedures to take place:
List out the treatments you will allow to take place
Date

MonthDayYear
Date
Consent Signature (Client, Parent or Legal Guardian)

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Upload a photo of the FRONT of your insurance card.
Upload a photo of the BACK of your insurance card.
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