 EMERGENCY MEDICAL AUTHORIZATION FORM
Courtesy of Medids.com
I, _________________________________________________________________________
Parent/ Son/ Daughter/ Guardian of ___________________________________________________________
Born on ___________________, do hereby give my consent to _________________________________________, to secure and authorize
such emergency medical treatment as the above name might require while under
the supervision of said care provider. I also agree to pay all the costs and fees
contingent on emergency medical care or treatment for this person as secured or
authorized under this consent.
NOTE: Every effort will be made to notify the parents/ son/ daughter/ guardian, etc. in case of an emergency.
In the even of an emergency, it would be necessary to have the following information:
Physician’s Name: ____________________ Phone Number: ____________________________
Preferred Hospital:_______________________________________________________________
Address: ______________________________ Phone: _________________________________
If the parents/ son/ daughter/ guardian is unavailable, other relatives or persons to contact in emergency:
Name:_________________________
Address:_________________________
Phone: ________________________
Relationship: _________________________
Signature of parents/ son/ daughter/ guardian : _____________________________________
Date: _________________________
Provider Signature: _____________________________________________
Date:________________________
above form!
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