Caregiver Consent Regarding Medical Treatment

Caregiver Consent regarding Medical and/or Emergency Treatment

I, as of hereinafter called Dependent, hereby voluntarily consent to the rendering to Dependent of such care, including diagnostic procedures, surgical and medical treatment and blood transfusions, by medical doctors, hospitals or their authorized designees, as may in their professional judgment be necessary to provide for the medical, surgical or emergency care of Dependent.

hereinafter called Caregiver, will be caring for Dependent for the period through . I hereby grant consent to Caregiver to arrange for routine or emergency medical and/or dental care and treatment necessary to preserve the health of Dependent. In the event that Dependent is injured or ill while under the care of the Caregiver, I hereby give permission to Caregiver to provide first aid for said Dependent and to take the appropriate measures, including contacting the Emergency Medical Service (EMS) system and arranging for transportation to the nearest emergency medical facility.

In making medical decisions on my behalf for the benefit of my Dependent, I direct that the Caregiver attempt to contact me. However, if medical care becomes essential, I give permission to the Caregiver to make such decisions regarding such treatment as deemed appropriate by the medical doctor, hospital or their authorized designee. In furtherance of any treatment decisions to be made by the Caregiver on my behalf for the benefit of my Dependent, I authorize the Caregiver to request, obtain, review and inspect any and all information bearing upon my Dependent’s health and relevant to any such decisions to be made respecting such treatment.

I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on the condition of my Dependent and that I am responsible for all reasonable charges in connection with the care and treatment rendered to my Dependent during this period.

The following information is being given in case of such sickness or accident requiring medical treatment:

Child or Ward’s Personal Information

Full Name:

Date of Birth:

Sex:

Color of Eyes:

Color of Hair:

Allergies:

Medical Conditions:

Social Security #:

Insurance Information

Employer:

Member No.:

Employee Social Security No.:

Administrator:

Group No.:

Confirmation Number:

Health Care Providers

Pediatrician Name:

Pediatrician Phone Number:

Dentist Name:

Dentist Phone Number:

Additional Phone Number:

Witness our signatures this .

(Acknowledgment form may vary by state)

Notary Acknowledgment - Parent(s)

STATE OF

COUNTY OF

Personally appeared before me, the undersigned authority in and for the said county and state, on this day of , , within my jurisdiction, the within named, who acknowledged that they executed the above and foregoing instrument.

My Commission expires:

Notary Acknowledgment - Guardian

STATE OF

COUNTY OF

Personally appeared before me, the undersigned authority in and for the said county and state, on this day of , , within my jurisdiction, the within named, who acknowledged that he executed the above and foregoing instrument.

My Commission expires: