|
Clinical Reference Systems: Pediatric Advisor 10.0
Temporary Authorization to Consent to Treat a Child
I (we)_____________________________________________________________
Name(s) and address(es) of parents
designate to _______________________________________________________
Name and address of designee
the power to consent in our absence to medical care for our
child(ren):
_________________________________ _______________________________
Name(s) and age(s) of child(ren)
_________________________________ _______________________________
Parent(s)' phone number: __________________________________________
Child(ren)'s physician(s): ________________________________________
Physician's address and phone number: _____________________________
___________________________________________________________________
Medical insurance company: ________________________________________
Policy #: _________________________________________________________
Dates of expected absence from ________________ to ________________
CHILD(REN)'S MEDICAL HISTORY
Chronic conditions________________________________________________
Medications that need to be given on a regular basis:
___________________ __________________________________________
Child's Name Medication name, dosage, frequency
___________________ __________________________________________
Child's Name Medication name, dosage, frequency
___________________ __________________________________________
Child's Name Medication name, dosage, frequency
Allergies:________________________________________________________
Dietary or other restrictions: ___________________________________
|
