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We, the undersigned parent(s) or guardian(s) of _____________________________, a minor, do
Minor’s Name________________________________________________________________________
hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital
service that may be rendered to said minor under the general or specific instructions of
_______________________________M.D., or any physician the organization specified in the
following paragraph may call, whether such diagnosis or treatment is rendered at the office of said physician
or at a licensed hospital. It is understood that reasonable effort will be made to contact the doctor listed
above before any other physician is called by the organization. It is further understood that this consent is
given in advance of any specific diagnosis or treatment which might be required and is given to authorize
_____________________________ or the ___________________________________________________
physician to exercise their best judgment as to the requirements of such diagnosis or treatment.
This consent shall remain in continuous effect until revoked in writing and delivered to the physician named
above or to the organization entrusted with the custody of said minor.
We hereby authorize any hospital, physician, or other person who has attended or examined the minor to
furnish to the Indiana Conference Health Care, or its representative, any and all information with respect to
any illness, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical
records. A photo static copy of this authorization shall be considered as effective and valid as the original.
On the reverse side of this consent is a description of the minor’s health concerns known to the parent or
guardian which should be considered when diagnosing or rendering treatment.
Dated:__________________________________
Home Phone Number: ____________________________
Emergency Phone Numbers: ___________________________ or ______________________________
________________________________________ ______________________________________
_______________________________________ _______________________________________
Father’s Name Mother’s Name
_______________________________________
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