An emergency medical authorization form gives whoever is responsible for a patient the power to consent to health checkup and treatment of a child. If the parent or the guardian is away in case of an emergency or a medical emergency, the medical authorization form can be used by the caretaker or the baby sitter to attend to the child or patient.
EMERGENCY MEDICAL AUTHORIZATION FORM
PART I. Family Information
Child’s Name _____________________________ Date of Birth _________________
Name of Parent or Guardian ______________________ Home phone _________________
Work phone ________________________ Address ___________________________
Name of Parent or Guardian ______________________ Home phone _________________
Work phone ________________________ Address ___________________________
Part II. Other persons who can be called in case of a medical emergency:
Care taker 1 Name _____________________________ Phone ______________________
Relationship ___________________________ Address ___________________________
Care taker 2 Name _____________________________ Phone ______________________
Relationship ___________________________ Address ___________________________
Part III. Doctor to be called in the event of an emergency:
Physician’s name _________________________________ Phone _________________
Address __________________________________________________________________
In the event that the physician cannot be reached, what action should be taken? _________________________________________________________________________
Name of Parent or Guardian __________________________________________________
Signature __________________________________ Date ________________________
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