I/We, _________________________________________, the undersigned parent or parents of ____________________________________, Birthdate:_______________
and_________________________________, Birthdate:_______________
and_________________________________, Birthdate:_______________
residing at _____________________________________________________________,
home phone# ____________, do hereby authorize ______________________ M.D. or _____________________ D.D.S. to perform or have performed by any physician or surgeon of his/her choice, at any time, any medical, dental, surgical, or anesthetic procedures which the said M.D. or D.D.S. may deem necessary for the well being and reasonable comfort of my/our said child or children in the event that I/we are not available. I/We agree to pay any hospital expenses incurred thereby. I/We are to be notified at the earliest opportunity thereafter.
This medical/dental authorization is being left with the person or persons in charge of my/our child/children in my/our absence, who has/have been instructed to contact ______________________, M.D. or _____________________, D.D.S in the event of illness or injury and has/have been further instructed to deliver this medical/dental authorization to said M.D. or D.D.S. at such time. In the event said M.D. or D.D.S. is not available, this medical/dental authorization shall be extended to any licensed physician/dentist handling his/her practice in his/her absence. I/We hereby authorize any hospital or physician which has provided treatment to the aforementioned minor to surrender physical custody of such minor to the accompanying caregiver.
Signed: ______________________________/__________________________________
Date: __________________
EMERGENCY CONTACTS
M.D. :___________________________________________ Phone: _______________
Address: _______________________________________________________________
D.D.S.: __________________________________________ Phone: _______________
Address:________________________________________________________________
Dad's work phone:_____________ Address:_________________________________
Mom's work phone: ____________ Address: ________________________________
Nearest relative or friend to contact in the event of an emergency:
Name:_____________________ Relationship: ____________ Phone: ____________
Address: _______________________________________________________________
Insurance: ______________ Group # ____________ Insured's name: ___________
Special needs/allergies:__________________________________________________