Child Healthcare Consent Form

CHILD HEALTHCARE CONSENT FORM

State of Alabama

I, ________, of ________, declare that I am the parent of the following child:

-- ________, Male, born on ________ in ________

My child has the following special medical needs and/or allergies:

________

I do hereby grant ________, of ________, the authority to obtain medical treatment as needed for the above listed child.

I grant ________ permission to do the following in service of seeking medical treatment for my child:

-- Obtain medical treatment/procedures for the child as may be appropriate or necessary in emergency situations, including and not limited to treatment by doctors, nurses, hospital and clinic personnel, and any other appropriate and qualified healthcare providers

-- Obtain routine medical treatment/procuedures for the child from appropriate and qualfied healthcare providers if symptoms of illness occur and ________ is reasonably certain medical treatment is necessary and in the best interest of the child

-- Administer medications prescribed to the child as directed and necessary

-- Administer over the counter medications to the child as prudent and necessary

If necessary, ________ should contact the following healthcare provider to provide medical information and consultation and set up an appointment if necessary:

-- ________

If the child require hospitalization, ________ should make every reasonable effort to use the following hospital:

-- ________

The authorized person may provide physicians, nurses, and other healthcare providers with the following health insurance information:

Insurance Company: ________

Policy Number: ________

Name of Policyholder: ________

This granting of authority shall begin on ________ and remain in effect until ________.

In case of an emergency, ________ should first contact the parent in the following manner:

-- ________

If the parent is not available in an emergency situation, ________ should contact the following alternative emergency contact:

-- ________

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