Fill and Sign the Consent Medical Form

Caregiver Consent regarding Medical and/or Emergency Treatment I, _________________________________ (Names of Parents or Guardian) , as ______________ (Parents or Guardian) of _________________ (name of child or ward) , 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. _____________________ (Name of Caregiver) , hereinafter called Caregiver , will be caring for Dependent for the period ________________ (date) through _________________ (date) . 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: _____________________________________  Phone Number: __________________________________ Dentist: Name: _________________________________________________  Phone Number: __________________________________________  Phone Number: _________________________________________________ Witness our signatures this ________________ (date) . ____________________________ ___________________________ (Printed Name of Parent) (Printed Name of Parent) ____________________________ ___________________________ (Signature of Parent) (Signature of Parent) _____________________________ (Printed Name of Guardian) _____________________________ (Signature of Guardian) (Acknowledgment form may vary by state) STATE OF ______________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for the said county and state, on this _____ day of _____________, 20____, within my jurisdiction, the within named, __________________________________ (Names of each Parent) , who acknowledged that they executed the above and fore going instrument. _____________________ NOTARY PUBLIC My Commission expires: ______________________ STATE OF ______________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for the said county and state, on this _____ day of _____________, 20_____, within my jurisdiction, the within named, ___________________ (Name of Guardian) , who acknowledged that he executed the above and fore going instrument. _____________________ NOTARY PUBLIC My Commission expires: ______________________