Emergency Card Info

1Applicant

2Medical Info

3Health Info

Name
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Submission ID
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Participant's Info
Participant's Name*
First Last
Date of Birth:*
DDD ID Number:*
Emergency Contact
Emergency Contact Name (other than parent)*
First Last
Emergency Contact Address:*
Street Address Address Line 2 City State ZIP Code
Emergency Contact Phone:*
Emergency Contact Email:*

Guardian Info
Guardian Name:*
First Last
Guardian Address:*
Street Address Address Line 2 City State ZIP Code
Guardian Phone Number:*
Guardian Email:*
Medical Information
Diagnosis:*
Current Medications:*
Any Special Medical Instructions:*
Physician Info
Physicians Name:*
Address*
Street Address Address Line 2 City State ZIP Code
Physician Phone:*
Physician Email:
Preferred Hospital:*

Health Information
Managed Care Organization (MCO) Information:
Private Insurance Information, If Available:
Administrative Services Organizations (ASO) if Applicable:
Medical or Surgical Treatment:
Hospital Admissions:
Examination and Diagnostic Procedures:
Anesthetics:
Transfusions:
Operations deemed necessary by competent medical clinicians to save or preserve the life of the named individual in the event of an emergency:
Consent
Name of person filling out this form:*
First Last
EMERGENCY CONSENT FORM

In my capacity as the legally appointed guardian of {Participant's Name (First):3.3} {Participant's Name (Last):3.6},

I hereby consent to any and all medical or surgical treatment, including hospital admission, examinations and diagnostic procedures, anesthetics, transfusions and operations, which, in the event of an emergency are deemed necessary by competent medical clinicians to save the life or preserve the health of the above named individual. I also approve the release from the case records of any medical history or other medical data, which would be necessary for the physician and/or hospital to administer the treatment.

It is understood that general consent is only applicable specifically and exclusively to emergency situations. In each and every other instance of elective medical and/or surgical treatment recommended by medical professionals, an explicit, individual consent must be requested within a reasonable advance time period.

Emergency treatment should be followed by prompt notification of the guardian by the person(s) responsible for care of the individual.
Signature*
Your Name
Your Name
Your Name

Emergency Card Info

Emergency Card Info

Participant's Info

Emergency Contact

Guardian Info

Medical Information

Physician Info

Health Information

Consent

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