Consent For Treatment
I, , do hereby consent to any X-ray examination, anesthetic, medical or surgical diagnosis, or treatment, and hospital service that may be rendered, under the general, specific or special instructions of any physician, whether such diagnosis or treatment is rendered at the office of said physician, or at a hospital licensed by the state. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but it is given to encourage those persons who have temporary custody of my child or children and said physician to exercise their best judgment as to the requirements of such diagnosis or medical or surgical treatment. This consent shall remain effective through December 15, 2023. I further agree to be responsible for payment of medical expense incurred under this consent.
PARTICIPANT INFORMATIONParticipant Name: DOB: MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Gender: GenderMaleFemale
PRIMARY EMERGENCY CONTACT Name: Relation: Email: Primary Phone Number: Secondary Phone Number:
SECONDARY EMERGENCY CONTACT Name: Relation: Email: Primary Phone Number: Secondary Phone Number:
FULL TIME PHYSICAL RESIDENCE ADDRESS:
EMERGENCY CONTACT INFORMATIONAdditional Emergency Contacts #1) Name: #1) Phone Number: #2) Name: #2) Phone Number:
PRIMARY PHYSICIAN INFORMATIONName: Phone Number: Address:
INSURANCE CARRIER INFORMATIONCarrier: Policy Number: Group Number: Authorization Number:
BASIC MEDICAL INFORMATIONAllergies:
Do you have a medical or mental condition that the coaches should be aware of?
Do you take any medication?
Date: November 28, 2022
Signature of Participant:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent For Treatment
Agree & Sign