Consent to Treat
Physicians and hospitals are authorized to photocopy this medical record. In case of emergency, I, , authorize anyone to administer first aid and Any licensed physician to render medical treatment and perform necessary surgery. When time permits, the need for major surgery must be agreeded upon by two qualified physicians. The surgeon may select the anesthetist of his/her choice.

I hereby authorize any physician or hospital to furnish full information concerning my medical condition and medical history to anyone rendering medical treatment to me or my child.



In case of emergency, I, , authorize the following person/s to discuss my medical condition with physicians, hospitals and or other healthcare providers.

Name: Relationship:

Name: Relationship:

Name: Relationship:


This form was completed by:

Date completed: MM/DD/YYYY

This form provided as a courtesy of JCDiaz.Net



Back to Forms Page