Fillable Printable Medical Service Consent Form

Medical Service Consent Form

DEPARTMENT OF CHILDREN AND FAMILIES

Division of Safety and Permanence

MEDICAL SERVICES CONSENT

Use of form: Use of this form is voluntary, but completion will aid caretakers in ensuring that appropriate and timely health care is provided.

The form is to be completed by the parent o r guardian of a child placed in foster care or treatment foster care. Personal ly identifiable

information on this form will be used for iden tification purposes and to assure appropriate medical care for the child. Personal inform ation you

provide may be used for secondary pur poses [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

Instructions: If additional space is needed, attach a separate sheet or use reverse side of this form.

Name – Parent or Guardian (Last, First, MI)

Name – Child (Last, First, MI)

Birthdate – Child (mm/dd/yyyy)

A. Routine Medical Serv ices Consent and Exclusions

For purposes of routine medical services for the ab ove named child, I hereby give my consent for the child placing agency or its designee to

approve the provision of routine medical ser vices*, including medical and dental examinations and nonemergency prescribed treatments (e.g.,

tooth repair, immunizations, m edications, reproductive health needs assessment), with the following exceptions:

* All medical services will be under the direc tion of a licensed dental care provider or physician or other licensed professional as appropriate.

B. Routine Emergency Medical Serv ices Consent and Exclusions

In case of a medical emergency involving the above named child, I understand that the following procedures will be used. I hereby give my

consent for the child placing a gency or its designee to arrange for emergency medical services using the following procedures:

1. A reasonable effort will be made to contact me and secure my consent for needed medi cal services, including surgical

procedures.

2. If I cannot be located within a reasonable time, the placing agency has the authority to consent to emergency surgery.

3. The juvenile court has the authority to consent to other medical services.

4. All medical services will be under the directio n of a licensed dental care provider or physician or other licensed professional as

appropriate.

I have no objections to the placing agency exercising its authority, with the following exceptions:

C. Parent / Guardian Information

Address – Home (Street, City, State, Zip Code)

Telephone Number – Home

Address – Work (Street, City, State, Zip Code)

Telephone Number – Work

Address – Other (Specify)

Telephone Nu mber – Other (Specify)

Address – Other (Specify)

Telephone Nu mber – Other (Specify)

SIGNATURE – Parent / Guardian

Date Signed

SIGNATURE – Child (age 14 and over only)

Date Signed

DCF-F-CFS0997 (R. 07/2010)