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Consent to Treatment Form- On Campus
CONTINUING CONSENT TO TREATMENT
AND HEALTH INSURANCE INFORMATION
(On Campus – keep in student cum folder)
We, the undersigned parents or guardian of __________________________________________,
Name of student or member
a minor, do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered to said minor under the general or special instruction of _______________________________________________, M.D., or any physician
Name of Physicians
the school or organization may call, whether such diagnosis or treatment is rendered at the office of said physician or at a licensed hospital. It is understood that reasonable effort will be made to contact the doctor listed above before the school or other organization calls any other physician.
It is further understood that this consent is given in advance of any specific diagnosis or treatment that might be required and is given to authorize _________________________________________________
Name of organization into whose custody minor is entrusted
or the physician to exercise their best judgment as to the requirements of such diagnosis or treatment.
This consent shall remain in continuous effect until revoked in writing and delivered to the physician named above or to the school or organization entrusted with the custody of said minor.
The above named student is ___, is not ___covered by health insurance.
Present Health Insurance Company ____________________ Policy Number _________________
Signature of Father Date
Signature of Mother Date
Signature of Guardian Date
Parents Names: _______________________________________
Phone – Father - home ( )____________ work ( )______________ Cell ( )____________
Phone – Mother - home ( )____________ work ( )______________ Cell ( )____________
C:\My Documents\Red Book\Consent to Treat on campus.doc