Medical Consent Form 
In case of emergency, ____________________________has my  consent to authorize medical care for my child(ren) listed below: 
Our family physician is: ___________________________________ His/her address is: _______________________________________ His/her telephone # is: ____________________________________ Our hospital preference is: _________________________________ Allergies: _______________________________________________ Contact me immediately at: ________________________________ If unable to contact me, please call: 
____________________________@_________________________ Name Telephone 
____________________________@_________________________ Name Telephone 
Signed by 
Name: _________________________________________________ Address: _______________________________________________ Telephone: _____________________________________________ Date: ________________________
Copyright 2002, VPMom.com – Advance in Career and Family 
Medical Consent Form 
NOTES:
Copyright 2002, VPMom.com – Advance in Career and Family