| Effective Dates:
EMERGENCY MEDICAL INFORMATION
Child’s Name:
Date of Birth: Home Phone:
Parents name:
Fathers Employer and Phone:
Mothers Employer and Phone:
Insurance Co. and ID#:
Childs Last Tetanus Shot:
List of Allergies:
Name and Phone Number of Person to Call in Emergency (other than parent’s):
Child’s Physician:
Past Medical History:
List of people with permission to sign for medical treatment:
1.
2.
3.
4.
5.
Additional Comments:
PARENT'S SIGNATURES: DATE:
Mother’s Signature:
Father’s Signature:
*Notary Public:
*This must be notarized for the hospital to be able to keep on file.
Please fill out this form, including the effective dates at the top of the page. This would be the date the child or children listed turn eighteen and the form is no longer needed. If several children are listed, just enter the date when the youngest one will be eighteen. Have the form notarized by a notary public and bring it to the hospital or send it to the address below. It will be placed in our record book and in our computer, which will be available to all ER personnel. Then the next time you are out of town working or unavailable, you can feel secure in knowing that your child will receive prompt medical attention.
Demonstration Hospital
105 Continental Place
Brentwood, TN 37027-5014
Attn: Emergency Room - Parental Permission for Treatment |