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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

Physician  
Name of practice  
Phone  
Other doctor  
Name of practice  
Phone  

Health Insurance Information

Insurance provider  
Address  
Group Number  
Subscriber Number  

Critical Info

Blood type  
Allergies  
Medications regularly taken  

Signature(s)

Name  
Relationship to child  
Name  
Relationship to child  

 

Featured Sites:

Cord Blood Registry
March of Dimes
Susan G. Komen


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