Emergency Room Consent Form
Print and complete this form, then return to DCH Emergency Department
Consent to Emergency Care
Consent for emergency medical treatment of minors
temporarily separated from their Parents or Guardian.
Time Period:
From ________________________
Through __________________________
Date
Date
Minor's Name
_________________________________
Minor's Social Security Number
______________
Date of Birth
_______________________________
Address
___________________________________________
City/State/Zip
__________________________
Home Phone
_______________________________
Next of Kin:
Mother's Name____________________________
Work Phone Number__________________
Father's Name_____________________________
Work Phone Number__________________
Name of Insurance
_______________________________
Name of Policy Holder
_____________________
Employer
______________________________________
Policy Number
_____________________________
Group Number
_________________________________
Benefit
____________________________________
Family or Personal Physician
_________________________
City
_____________
Phone
______________
Surgeon
__________________________________________
City
______________
Phone
______________
Medications or Medical Disorders (include any medications prescribed in recent weeks and any recent illnesses)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Tetanus or Baby Shots
___________________________
Allergies
__________________________________
Height
_________________________
Weight
_________________________
Name(s) of Person(s) responsible to sign for the above named child as designated by parents:
Name
_____________________________________________
Phone
_____________________________
Name
_____________________________________________
Phone
_____________________________
I (We) understand and agree that I (we) am (are) responsible for any and all costs and expenses for emergency care and/or medical care in treatment rendered to the above named minor. I (We)understand I (we) will be billed for these services and I (we) may assign benefits to Daviess Community Hospital due under the insurance carrier.
Signed
_________________________________________
Date
___________
Father or Legal Guardian
Signed
_________________________________________
Date
___________
Mother or Legal Guardian
Complete and mail/bring to Daviess Community Hospital Emergency Department
ORIGINAL to Health Information Services
ONE COPY to Emergency Department ONE COPY to Admitting Office