Emergency Treatment Form

Name of Child

Grade of Child

Age of Child

Date of Birth

YYYY

Parent / Guardian Name

Parent / Guardian Phone Number

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Alternative Parent / Guardian Name

Relationship of Alternative Parent / Guardian Name

Alternative Parent / Guardian Phone Number

(###)

###

####

Insurance Name

Insurance Policy and Group Numbers

Allergies

Any other information necessary for care?

Parent / Guardian Name for Consent

To All Parents:

Emergency Treatment Form

Since the malpractice question has come to the forefront, many hospitals and doctors will not treat a child without parent’s consent (unless a matter of life or death). It is requested that you complete the information below so that if your child requires a visit to the hospital while under the supervision of SMILA, this will allow the hospital to treat the injury. BY CLICKING “SEND” I AGREE TO BE LEGALLY BOUND. SUBMITTING THIS FORM CONSTITUTES AN ELECTRONIC SIGNATURE AND AGREE THAT SMILA AND ALL HEALTHCARE PROVIDERS MAY RELY ON THIS SIGNATURE AS BINDING. I also agree to be solely liable for the cost of care and indemnify and hold SMILA harmless for any cost, expense, claim, liability or any loss whatsoever including the cost of collection, interest, attorney’s fees, and expenses.

Emergency Treatment Form

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