PART I (TO GRANT CONSENT)
In the event reasonable attempts to contact me at
(a)_________________ (phone) or
(b)___________________(other
parent) at
(c)________________ (phone) have been unsuccessful, I HEREBY GIVE MY CONSENT for (1) the
administration of any treatment deemed necessary by (preferred physician) Dr.
(d)______________________________
at
(e)___________________(phone), or (preferred dentist) Dr.
at
(f)_______________
(g)___________________(phone), or
in the event the DESIGNATED preferred practitioner is not available, by another licensed physician or dentist; and
(2) the transfer of the child to Nationwide Children’s Hospital (preferred hospital) or any hospital reasonably
accessible. This authorization does not cover major surgery unless the medical opinions of two licensed physicians
or dentists, concurring in the necessity for such surgery, are obtained before surgery is performed.
FACTS CONCERNING THE CHILD’S MEDICAL HISTORY INCLUDING ALLERGIES, MEDICATIONS
BEING TAKEN, AND ANY PHYSICAL IMPAIRMENTS to which a physician should be alerted:
(h)________________________________________________________________________________________
(please enter your answers by entering the coordinating letter to each of your answers)
