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Emergency Consent to Treat
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Columbia Adventist Academy

Emergency Consent to Treatment
Print two.

 
School Year

Student's Name

Home Number(s)
Mother's Name

Work Number(s)
Father's Name

Work Number(s)
Legal Guardian

Work Number(s)
Doctor's Name

Office Number
Preferred Local Hospital
We, the undersigned parents or legal guardian of the above student, do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital services that may be rendered. It is understood that reasonable effort will be made to contact the parent/guardian and the doctor listed above before any other physician is called by the school. It is understood that this consent is given in advance of any specific diagnosis or treatment which might be required.

Present Family Health Insurance Company

Policy Number
       
       
 
Parent or Legal Guardian   Date

 

 

 

 
241 Riverchase Way • Lexington, SC, 29072-9470 • 803-796-0277