Free Medical Treatment Authorization Form Template
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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