| 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.
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| Minor's Name_________________________________ Minor's Social Security Number______________ |
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| Date of Birth_______________________________ |
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| Address___________________________________________ City/State/Zip__________________________ |
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| Home Phone_______________________________ |
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| Next of Kin: | Mother's Name____________________________ Work Phone Number__________________ |
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| Father's Name_____________________________ Work Phone Number__________________ |
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| Name of Insurance_______________________________ Name of Policy Holder_____________________ |
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| Employer______________________________________ Policy Number_____________________________ |
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| Group Number_________________________________ Benefit____________________________________ |
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| Family or Personal Physician_________________________ City_____________ Phone______________ |
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| Surgeon__________________________________________ City______________ Phone______________ |
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| Medications or Medical Disorders (include any medications prescribed in recent weeks and any recent illnesses) |
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| ______________________________________________________________________________________________________ |
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| ______________________________________________________________________________________________________ |
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| Tetanus or Baby Shots___________________________ Allergies__________________________________ |
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| Height_________________________ Weight_________________________ |
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| Name(s) of Person(s) responsible to sign for the above named child as designated by parents: |
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| Name_____________________________________________ Phone_____________________________ |
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| Name_____________________________________________ Phone_____________________________ |
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| 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. |
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| Signed_________________________________________ Date___________ |
Father or Legal Guardian |
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| 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 |