AUTHORIZATION FOR TREATMENT OF A MINOR |
--
DATE _________________
I,_________________________________ , being the parent or legal guardian of___________________________________, give my consent for emergency medical and surgical treatment of this minor in a licensed hospital by a licensed Tennessee physician should his/her condition so require it in my absence. I understand that in such a case, reasonable attempts would first be made to contact me, time and conditions permitting.
As long as the medical or surgical treatment considered necessary in the situation is in accordance with generally accepted standards of medical practice for the particular type of injury or illness involved, I impose no specific limitations or prohibitions regarding treatment other than those that follow: (If none, so state)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________ |
--
This authorization is in effect for the following time period: |
______________________to_______________________ |
--
PARENTS' SIGNATURES: DATE:
Mother’s Signature:
Father’s Signature:
*Notary Public:
*This must be notarized for the hospital to use.
|
____________________________________________________________________________ |
Parents' Names (please print) |
| -- |
____________________________________________________________________________ |
Street |
--
__________________ | _________________ | _________________ | __________________ |
City | State | Zip | Phone Number |
--
| ____________________________________________________________________________ |
| Father’s Workplace | Address | Phone |
--
| ____________________________________________________________________________ |
| Mother’s Workplace | Address | Phone |
--
| ____________________________________________________________________________ |
| Other Contact Person | Address | Phone |
--
| ____________________________________________________________________________ |
Family Doctor | Phone |
--
| ____________________________________________________________________________ |
Preferred Surgeon | Phone |
--
| Medical Insurance Carrier ______________________________________________ |
 | Identification Number _____________________________________ |
| Member’s Name _________________________________________ |
| Benefit Code ____________________________________________ |
| Account Number _________________________________________ |
--
| Medical History/Allergies, if any, including medication |
| ____________________________________________________________________________ |
| ____________________________________________________________________________ |
--
| Chronic or existing diseases or medical problems (e.g. diabetes, epilepsy) |
| ____________________________________________________________________________ |
| ____________________________________________________________________________ |
--
| Medicines your child is taking now |
| ____________________________________________________________________________ |
| ____________________________________________________________________________ |
--
| In an emergency, parents can be reached as follows |
| ____________________________________________________________________________ |
| ____________________________________________________________________________ |
Fax to:
(615) 371-4600
or Deliver or Mail to:
Demonstration Hospital
Attn: Emergency Room
105 Continental Place
Brentwood, TN 37027-5014 |