Consent for Emergency Medical Treatment

Name of Child(Required)

First Last

Faculty Name(Required)

TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR

Name(Required)

THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL-BEING OF THE CHILD NAMED ABOVE.

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:(Required)

HOME ADDRESS(Required)

Street Address City ZIP Code

HOME PHONE(Required)

WORK PHONE(Required)

Name(Required)

First Last

Parent / Guardian Email(Required)

DATE(Required)

Parent / Guardian Signature(Required)

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Comments

This field is for validation purposes and should be left unchanged.