Transcription of CONSENT FOR EMERGENCY MEDICAL TREATMENT-Child …
1 ( )( )STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCONSENT FOR EMERGENCY MEDICAL TREATMENT-Child Care Centers Or Family Child Care HomesAS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO_____ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE FACILITY NAMEPRESCRIBED BY A DULY LICENSED PHYSICIAN ( ) OSTEOPATH ( ) OR DENTIST ( ) FOR_____. THIS CARE MAY BE GIVEN UNDER NAMEWHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILDNAMED OR AUTHORIZED REPRESENTATIVE SIGNATURECHILD HAS THE FOLLOWING MEDICATION ALLERGIES:HOME ADDRESSHOME PHONELIC 627 (9/08) (CONFIDENTIAL)WORK PHONE
