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

                Email

                  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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