Escolar Documentos
Profissional Documentos
Cultura Documentos
Pre-Consent
Form for
Emergency Care
Presenting this
completed form means your
child can be treated more
quickly when you cannot be
located.
children.
Update the information every
time you go away.
Leave the completed form with
the person responsible for your
children in your absence.
Instruct those responsible to
take this form with him/her in the
case of a medical emergency.
Presented By:
Phone: 812-268-4311
Website: schosp.com
Sullivan County
Community Hospital
2200 North Section Street
P.O. Box 10
Sullivan, Indiana 47882-0010
Authorization for
Treatment of Minor
I, _________________, being the
parent or legal guardian of
__________________, give my
consent for emergency medical and
surgical treatment of this minor in
a licensed hospital by a licensed
physician should his/her condition so
require it in my absence. I understand
that in such a case reasonable attempts
would be made to contact me, time and
conditions permitting.
As long as the medical or surgical
treatment considered is necessary in
the situation and is in accordance with
generally accepted standards of
medical practice for the particular type
of injury or illness involved, I impose no
specific limitations or prohibitions
regarding treatment other than the
following (If none, so state): ________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
This authorization is effective for the
following time period: ___________
_______ to ___________________
____________________________
Parent or Legal Guardian Signature
_____________________________
Printed Name
_____________________________
Date
Address: ________________________________________________________________
City, State, Zip: ___________________________________________________________
Phone Number: ___________________________________________________________
Phone: _____________________________
Phone: _____________________________
Phone: _____________________________
Medical Information
Family Doctor: _______________________
Preferred Surgeon: ____________________
Phone: _____________________________
Phone: _____________________________
Insurance Information
Carrier: ____________________________
Members Name: _____________________
Account Number: _____________________
Medical History
Allergies, if any, including medications: ___________________________________________
_______________________________________________________________________
_______________________________________________________________________
Chronic or existing diseases or medical problems (e.g. diabetes, epilepsy): _________________
_______________________________________________________________________
_______________________________________________________________________
Medicines your child is taking now: _____________________________________________
_______________________________________________________________________
_______________________________________________________________________
In an emergency, parents or legal guardians can be reached as follows: __________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________