Arbeitsblatt: Medical Consent

CONSENT TO TREAT MINOR CHILDREN Please print all information I,, parent or legal guardian of, born , do hereby consent to any medical care and the administration of anesthesia determined by physician to be necessary for the welfare of my child while said child is under the care of and am not reasonably available by telephone to give consent. This authorization is effective from to . Signature of Parent or Legal Guardian Witness Signature Witness Name (please print) This consent form should be taken with the child to the hospital or physician office when the child is taken for treatment. This additional information will assist in treatment if it can be furnished with the consent but is not required. Family address Telephone: Father home work Mother home work Child Birthdate Last Tetanus Allergies to drugs or foods Special Medications, Blood Type or Pertinent Information Child Physician Phone Insurance Policy Preferred Hospital