COVID-19/CORONAVIRUS PANDEMIC CHILD HEALTHCARE CONSENT FORM
State of Alabama
I, ________, of ________, declare that I am the parent of the following child:
-- ________, Male, born on ________ in ________
My child has the following special medical needs and/or allergies:
________
I do hereby grant , of , the authority to obtain medical treatment as needed for the above listed child.
I grant permission to do the following in service of seeking medical treatment for my child:
-- Obtain medical treatment/procedures for the child as may be appropriate or necessary in emergency situations, including and not limited to treatment by doctors, nurses, hospital and clinic personnel, and any other appropriate and qualified healthcare providers
-- Obtain routine medical treatment/procuedures for the child from appropriate and qualfied healthcare providers if symptoms of illness occur and is reasonably certain medical treatment is necessary and in the best interest of the child
-- Administer medications prescribed to the child as directed and necessary
-- Administer over the counter medications to the child as prudent and necessary
-- Approve the use of a ventilator if necessary and recommended by a qualfied healthcare provider
If necessary, should contact the following healthcare provider to provide medical information and consultation and set up an appointment if necessary:
-- ________
If the child require hospitalization, should make every reasonable effort to use the following hospital:
-- ________
The authorized person may provide physicians, nurses, and other healthcare providers with the following health insurance information:
Insurance Company: ________
Policy Number: ________
Name of Policyholder: ________
This granting of authority shall begin on ________ and remain in effect until ________.
In case of an emergency, should first contact the parent in the following manner:
-- ________
If the parent is not available in an emergency situation, should contact the following alternative emergency contact:
-- ________
__________________________________
________
__________________
DATE