Medical Treatment Authorization Form printable pdf download

Medical Treatment Authorization Form

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an

emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible or practical to contact

them.

This form should be given to the trip leader or shown to the trip leader and then carried by the designated adult.

Minor Full Legal Name: ______________________________

Home Address: _________________________________________________

Date of Birth: _________________ Gender: Female_____ Male_____

Information for Medical Treatment

Physician’s Name and Location of Practice: _______________________________

________________________________________________

Physician’s Phone # (if known): (____) ________________

Medical Insurer/Health Plan: __________________________

Policy #: _______________________________

Allergies to Medications: __________________________________________________________________

Allergies (Other): ___________________________________________________________________

___________________________________________________________________

Please note all conditions for which the child is currently receiving treatment:

__________________________________________________________________________

Note any other significant medical information: ___________________________________

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for

_________________________________________ (hereafter “Designated Adult”) to administer general first aid treatment for any minor injuries or

illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to

summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood

transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general

the exercise of his or her best

supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly

judgment upon the advice of any such medical or emergency personnel. licensed to practice in the state in which such treatment is to

occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in

advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in

This authorization is effective through: _________. Signed this _____day of______, 20__

Parent / Legal Guardian Signature: ________________________

Printed Name: _____________________

Witness Signature: _____________________________________

Printed Name: ______________________________________

Medical Treatment Authorization Form

Related Articles

Related forms

Related Categories