Medical Consent Form CONSENT TO TREAT MINOR CHILDREN I, * First Name Last Name Parent or Guardian of: * First Name Last Name Born on: * MM DD YYYY I (stated above) do hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is under the care of Victorious Living Church, 388 Tremont Street, City of Rochester, State of New York and if I am not reasonably available by telephone to give consent. This authorization is effective from this date: * MM DD YYYY until this date: MM DD YYYY Electronic Signature Agreement. * By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. I Accept Electronic Signature * First Name Last Name This consent form should be taken with the child to the hospital or physician's office when the child is taken for treatment. This additional information will assist in treatment if it can be furnished with the consent but is not required. Family Address Address 1 Address 2 City State/Province Zip/Postal Code Country Father's Phone: * (###) ### #### Mother's Phone: * (###) ### #### Last Tetanus Shot: * MM DD YYYY Allergies to drugs or foods: * Special Medications, Blood Type or Pertinent Information: * Child's Physician: * Physician's Phone * (###) ### #### Insurance Provider: * Policy Number: * Preferred Hospital: * Thank you!
