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Hospital Permission Form to Authorize Treatment

In case of emergency, I give ______________________________ permission to authorize treatment of my child ______________________________.

Critical Information About My Child

Name Social Security Number Date of Birth

Medical Information

Name of practice  
Other doctor  
Name of practice  

Health Insurance Information

Insurance provider  
Group Number  
Subscriber Number  

Critical Info

Blood type  
Medications regularly taken  


Relationship to child  
Relationship to child  


Featured Sites:

Cord Blood Registry
March of Dimes
Susan G. Komen

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