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