Healthcare Child Packet

HEALTHCARE CHILD PACKET

Child Information

Child Name:    Date of Birth:    Gender:

Primary Phone:    Alternate Phone:    School/Daycare:

Parent / Legal Guardian Information

Mobile Phone:    Work Phone:

Emergency Contact

Relationship:    Phone:    Alternate Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

Has your child had seizures, asthma attacks, diabetes, or cardiac conditions?

Immunizations

Immunizations up to date:    Last Tdap/Booster Date:

Consent for Treatment

I, the undersigned parent or legal guardian, authorize medical and emergency care for the child named in this packet. This authorization includes routine diagnostic procedures, administration of medications as indicated below, and emergency transport to an appropriate medical facility when, in the reasonable judgment of the attending clinician, delay would jeopardize the child's health. I understand risks inherent to medical treatment and consent to the treatment described by the treating clinician.

I understand that I may withdraw this consent at any time in writing, except to the extent that care has already been provided in reliance on this authorization.

Medication Administration Consent (Facility Use)

Permission is granted to administer the following over-the-counter medications when appropriate for the child's reported symptoms. I affirm that dosing instructions below are accurate and understand staff will follow standard dosing guidelines unless otherwise specified.

  Acetaminophen (children's) — Dose instructions:

  Ibuprofen (children's) — Dose instructions:

  Antihistamine (e.g., for allergic reactions) — Dose instructions:

HIPAA / Privacy Authorization

I acknowledge that I have received or been offered a copy of the facility's Notice of Privacy Practices describing how protected health information may be used and disclosed. I authorize the facility and its staff to disclose relevant medical information about my child to the following persons or entities as necessary for care, billing, and coordination of services:

Authorization expiration date:

Photography / Media Release

  I grant permission for my child's photograph/video to be taken and used by the facility for treatment identification, internal education, or non-commercial informational materials with de-identification where feasible.

  I DO NOT consent to photographs/videos of my child for any purpose beyond direct clinical care.

Release and Certification

By signing below I certify that the information provided in this packet is true and complete to the best of my knowledge. I authorize release of medical and billing information as necessary to process claims and coordinate care. I understand that falsification of material facts, including insurance information, may result in denial of services or other administrative action.

I further certify that I am the parent or legal guardian of the child named herein and that I have authority to consent to treatment. I understand that I am financially responsible for charges not covered by insurance and that reasonable efforts will be made to obtain consent prior to non-emergency procedures whenever practicable.

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