Medical Consent Form

A medial consent form can be used to enable you to get prompt medical attention thus, avoiding unnecessary delays in an emergency situation. Completing this form gives an informed consent or pre-authorizes the medical caregivers to offer treatment to any specified person as indicated on the form should a medical situation arise. Below is a sample medical consent form.

Sample Medical Consent Form

Full name: ______________________________________

Address: _____________________________________________

Age: ____________________________________________________

The undersigned hereby authorize any X-ray, medical, anesthetic, dental or any other hospital care to be accorded to _________________________   (name of person)  as considered advisable and is provided under the supervision of any physician or surgeon licensed under the _________________________ whether the treatment is offered at hospital or elsewhere.

Parent or guardian name: ____________________________________________

Parent or guardian signature: ____________________________________________

Date: ____________________________________________

Address of parent or guardian: ____________________________________________

Witness name and signature: ____________________________________________

Parent insurance details: ____________________________________________

Family doctor: ____________________________________________

Family doctor’s full address: ____________________________________________

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