Emergency Room / Medical Services Authorization


The undersigned hereby certify that they are the parent / legal guardian of:

Child's Name:

Date of Birth:


The undersigned recognizes that there may be circumstances in which he / she may not be available to give consent for medical treatment required by a hospital for the above mentioned child. By this document, the undersigned hereby authorizes a doctor or doctors employed by any emergency room of a hospital to perform such medical services or procedures that are considered necessary in connection with an injury or illness the said child may have, wherever he / she may be located and if the undersigned are not available to consent at said time.


Insurer:

Insurance Number and Company:

Child's Physician: Phone Number:

Child's Dentist: Phone Number:

Child's Allergies:

Child's Medication(s):

How long has the child been taking the medication?

What is the reason for the medication?

Is there any other information about your child that medical emergency personnel would need to know?

Leave this empty:

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Signature Certificate
Document name: Emergency Room / Medical Services Authorization
lock iconUnique Document ID: 3e988de21c0c559dca1175817dfac1f44b3ddad8
Timestamp Audit
April 19, 2021 3:06 pm CDTEmergency Room / Medical Services Authorization Uploaded by Joe Massaro - jmassaro@capeevansville.org IP 96.27.254.146