Medical Treatment Authorization Form
Medical Treatment Authorization Form
Please complete this form to provide consent for medical care.
Patient Information
Name
Date of Birth
Insurance Provider
Policy Number
Parent/Guardian Information
Name
Address
Phone number
Authorized Physician Details
Name
Address
Phone number
Medical Information
Allergies
Specify any medical or food allergies:
Medical Condition
Specify any current medical conditions:
Medications
List down any treatments the patient is receiving:
Authorized Procedures
Please check all that apply:
-
First Aid
-
Administration of Prescription Medications
-
Blood Transfusion
-
Emergency Surgery
-
X-Ray, MRI, or Other Diagnostic Procedures
-
Hospital Admission
-
Transport to Another Hospital
-
Intravenous (IV) Therapy
-
Anesthesia Administration
-
Vaccinations (Routine and Emergency)
-
Declaration
I hereby declare that I have full custody and legal authority to make medical decisions for the patient named above. I authorize the listed procedures and consent to medical treatment as deemed necessary by authorized medical personnel. I agree to assume full responsibility for any expenses incurred due to the medical treatment provided.
Name:
Date:
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