Emergency Medical Consent Form
Please Print
____________________________has my permission to obtain emergency
medical treatment for my child, ___________________________________when
I cannot be present.
Child Date of Birth_____________
Parent/Guardian’s Name________________________________________
Phone_______________________
E-Mail address________________________________________________
Insurance Holders Name________________________________________
Insurance holders date of birth__________
Last 4 digits of SS number______
Insurance Provider____________________
Insurance ID _______________
Child’s Medication__________________________________________
Child’s Allergies____________________________________________
PCP______________________________________________________
___ I understand that I assume all financial responsibility for any medical
treatment or injuries sustained by the patient.
_________________________
__________
Signature of Parent/Guardian
Date
Please provide a copy of child’s insurance card and insurance holders ID