CONSENT TO TREAT MINOR CHILDREN
I,
Parent Name/Legal Guardian
parent or legal guardian of
Childs Name
born the day of
Birthdate (XX/XX/XXXX)
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
Lorenzo Thomas
of
Guts Church
in the City of
we will be in Van Buren, MO
in the State of
we will be in Missouri
and I am not reasonably available by telephone to give consent.
This authorization is effective from the day of
We leave June 8th
to the day of
We return June 11th
Signature of Parent or Legal Guardian
Signature
Date
/
Month
/
Day
Year
Date
Parent Email
example@example.com
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
Parent/Guardian Telephone
Format: (000) 000-0000.
Parent/Guardian Telephone
Format: (000) 000-0000.
Last Tetanus
Allergies to drugs or foods
Special Medications, Blood Type or Pertinent Information
Special Medications, Blood Type or Pertinent Information
Child's Physician
Physician Phone Number
Format: (000) 000-0000.
Insurance
Policy #
Preferred Hospital
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