Arden Hill Hospital

Goshen, New York 10924

 

Authorization For Emergency Treatment Of Minors

(Anyone Under The Age Of Eighteen)

 

 

Date______________________________            Time________________________(AM)(PM)

 

Names of                                                        Date of         Family Physician

Minors                        Birth Date           Last Tetanus            Name & Phone #            Allergies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I/We being the parent(s) or legal guardians of the above names minor(s), do hereby appoint:

English Rose Day School

16 Weathervane Drive                                                   

                        Washingtonville, NY 10992

845-496-4455

To act in my/our behalf in authorizing emergency medical, dental, surgical care and hospitalization for the above named minor(s) during the period of my/our absence:

 

Month: ______ Day: ______ Year: _____ through Month: ______ Day: ______ Year: ______

 

This document shall be presented to a physician, dentist, or appropriate hospital representative at such time as emergency medical, dental, surgical care or hospitalization may be required.  This document shall not be construed as consent to medical, dental or surgical treatment of an elective nature if such treatment can be postponed until I am available to consent to such care personally.  Treatment shall be considered elective if, in the treating physician’s judgment, it can be delayed until I am available to consent without serious negative impact to my child’s health or welfare.

 

I agree that I am responsible for the costs and expenses for medical, dental or surgical care and hospitalization rendered to the above-named minor at the direction of the individual(s) I/we have appointed herein.

 

Hospitalization coverage for the above-named minor(s):

 

Name of Insurance Company or                                                                  Identification or

Government Program                                                                                   Contract Number

 

___________________________                                                      _______________________

Authorization for Emergency Treatment of Minors                         Page ---------2

(Anyone under the age of eighteen)

 

 

 

Parent/Legal Guardian(s) Name (print)            _________________________________

  Home Address                                                            _________________________________

  City, State, Zip                                                _________________________________

  Phone #                                                          _________________________________

 

  Business Address                                                _________________________________

  City, State, Zip                                                _________________________________

  Phone #                                                          _________________________________

  Signature                                                        _________________________________

 

 

Witness (Notary Public)

  Name                                                 ______________________________

  Signature                                            ______________________________

  Stamp

 

 

 

 

 

When, in the physican’s judgement, an emergency exists and your child is in immediate need of medical attention such that any delay in treatment would result in increased risk to your child’s life or health, parental consent will no be required.  In all other cases, no treatment will be provided until parental consent is obtained.  For those situations in which other than a “true emergency” exists, you can avoid unnecessary anxious moments for your child by making sure that the person in whose care you left the children knows where you can be reached while you are away from home or, for those times when it would be difficult to contact you, you can authorize other adults to give permission for necessary medical or dental care for you child.

 

This is a legal document.  With it you may appoint other adults to consent to medical treatment for your minor children when you cannot be reached to give such consent.  You can appoint relatives, friends, teachers, clergy, neighbors – anyone who is over eighteen years of age and who can be responsible for your children when you are away from them.  This is especially important for times when you know it will be difficult to reach you.

 

Fill out this form, or one similar to it, and give it to the adult(s) who can be responsible for you child while you are away.  If your child needs medical or dental attention, the responsible adult should present this document to the appropriate person – physician, hospital representative or dentist.  The responsible adult may then consent to treatment, which, in the physician’s judgment, should not wait until you are available to consent in person.  This form does not authorize that appointee to give consent to elective medical or dental treatments.

 

 

NOTE:  THIS FORM MUST BE MADE PART OF THE PATIENT’S MEDICAL RECORD.