Authorization for Emergency Medical Care *

In my absence, I authorize (adult into whose care minor (s) is entrusted) to act in my place to consent to medical treatment or hospital care as deemed advisable by any licensed physician/surgeon. I assume financial responsibility for the delivery of such care.

Yes, I will be reponsible

Name of person responsible *

First Name

Last Name

Phone number *

(###)

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I can be reached at phone number *

(###)

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Phone number of person *

(###)

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Doctor's Phone Number *

(###)

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Parent/Legal Guardian's Signature (electronic signature) *

First Name

Last Name

Date *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

Date of Birth

MM

DD

YYYY