If you have more than one child, please note the child's name in each note below as appropriate.

PARENT/GUARDIAN EMERGENCY MEDICAL TREATMENT APPROVAL PARENT/GUARDIAN EMERGENCY MEDICAL TREATMENT APPROVAL EMERGENCY AUTHORIZATION: In the event I cannot be reached, I give permission to medical personnel to order X-rays, routine tests, and treatment for my child. If I cannot be reached, I give permission for a qualified physician to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child.