Fillable Printable Consent for Emergency Medical Treatment for Child Care Centers - California

Consent for Emergency Medical Treatment for Child Care Centers - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CONSENT FOR EMERGENCY MEDICAL TREATMENT-

Child Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

_________________________________________ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE

FACILITY NAME

PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR

__________________________________________________ . THIS CARE MAY BE GIVEN UNDER

NAME

WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD

NAMED ABOVE.

DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:

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LIC 627 (9/08) (CONFIDENTIAL)

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