Medical Information Form

Address *

The undersigned hereby agree and consent to the administration of over-the-counter medicines (e.g., Tylenol, Pepto-Bismol) to the above named child or youth for minor ailments. *

In case of emergency, I (we) authorize the adult in charge to consent to medical care, or dental care, or both, for my/our minor child. *

The term “medical care” shall include, but not be limited to x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care under the general or special supervision rendered by a licensed physician or surgeon. *

For purposes of this consent, the term “dental care” shall include but not be limited to, x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care by a licenses dentist. *

I (we) authorize any and all of my child’s health care providers to release or disclose any and all protected health information relevant to the diagnosis / treatment of any physical, mental, and or emotional condition of my child to the adult in charge. *

I/we understand that information used or disclosed pursuant to this consent may be subject to re-disclosure by the above named person and may no longer be protected by federal or state law. *

This Authorization shall extend to and include, but not be limited to, my child’s medical history, including specific progress notes regarding any problems that would impact any surgery or procedures. *

The Authorization also includes the results of relevant diagnostic or laboratory tests, and were necessary, my child’s entire medical record. *

Medical Information *

Include Allergies, prescriptions, special needs, etc. Input NONE if none

Parent(s) or Guardian(s) *

Please Check all that apply

Father

Mother

Guardian

Electronic Signature

By my electronic signature below, I hereby certify and affirm that the information in this form is accurate to the best of my knowledge. I also agree that I will hold harmless Haven Community Church and its agents, employees, the employing or judicial authority or any other entity from any and all claims, liabilities, and causes of action.

Parent Consent to Medical Treatment

Parent / Guardian Information

Electronic Signature