Authorization to Treat A Minor

I, the undersigned parent or legal guardian of

 
Do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis, rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital or clinic.

  
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to render care that the aforementioned physician in the exercise of best judgment may deem advisable. It is understood that every effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.   
 

List any restrictions:

 
I hereby authorize and consent to the examination and/or treatment of minor illness of injury that might occur while at a school activity, by a licensed M.D., or R.N., who from time-to-time, would be in attendance as a first-aid provider for that activity.

  
I hereby authorize and consent fo the following over-the-counter medication being dispensed to my minor child by the Managers:

Check All Authorized Medications:  
Benedryl  
Tylenol  
Advil  
Tums  
Sudafed  
Other  
 
If you selected "other" please specify:
 
I hereby authorize and consent to the Managers dispensing the following prescription medication(s) to my minor child:  
 

Prescription Medication 1:
Prescription Medication 2:
Prescription Medication 3:
Prescription Medication 4:

 
I will give the prescription medication(s) to the Managers in a zip-locked bag clearly marked with my child's name; with written dispensing instructions and any pertinent information inside the bag. Dispensing of any medications, whether over-the counter or prescription, will be done in a confidential manner.  
 

Birth date:
Last Tetanus Toxin Booster:

 
Does you child have any allergies to foods or medicine? Please describe:
 
Does your child take any special medications? Please include any pertinent information.
 
Please include the following contact information:

Home Phone:
Work Phone:
Cellular Phone:
Home Address:
City:
State:
Zip Code:

 
Please include the following contact information for your Family's Physician

Name:
Office Address:
City:
State:
Zip Code:

 
Please answer the following questions about your insurance company:

Organization Employed By:
Healthcare Provider:
Policy Number: