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 INFORMATION
Participant Name: 
DOB:   
Gender:   


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 INFORMATION
Additional Emergency Contacts
#1) Name:   
#1) Phone Number:   

#2) Name:  
#2) Phone Number:   

 

PRIMARY PHYSICIAN INFORMATION
Name:  
Phone Number:   
Address: 

 


INSURANCE CARRIER INFORMATION
Carrier:   
Policy Number:   
Group Number:   
Authorization Number:   


BASIC MEDICAL INFORMATION
Allergies:

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:

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Signature Certificate
Document name: Consent For Treatment
lock iconUnique Document ID: abda01773d69b4664e12293f4768ce53eea5501f
Timestamp Audit
January 1, 2022 4:43 pm PSTConsent For Treatment Uploaded by Barbara Boucher - barbaraboucher@charter.net IP 98.171.91.162
January 1, 2022 4:48 pm PST Document owner mail@snowsummitraceteam.org has handed over this document to barbaraboucher@charter.net 2022-01-01 16:48:38 - 98.171.91.138