Emergency Room / Medical Services Authorization

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


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.