Hospital Permission Form to Authorize Treatment
In case of emergency, I give ______________________________ permission to authorize treatment of my child ______________________________.
Critical Information About My Child
| Name |
Social Security Number |
Date of Birth |
| |
|
|
Medical Information
| Physician |
|
| Name of practice |
|
| Phone |
|
| Other doctor |
|
| Name of practice |
|
| Phone |
|
Health Insurance Information
| Insurance provider |
|
| Address |
|
| Group Number |
|
| Subscriber Number |
|
Critical Info
| Blood type |
|
| Allergies |
|
| Medications regularly taken |
|
Signature(s)
| Name |
|
| Relationship to child |
|
| Name |
|
| Relationship to child |
|
| 
