Pediatric Emergency Contact and Medical Authorization Form

Patient Information

• Child's Full Name: ____________________
• Date of Birth: //___
• Home Address: ____________________
• Primary Language: ____________________

Parent/Guardian Information

Primary Contact

• Name: ____________________
• Relationship to Child: ____________________
• Phone Numbers:
  • Home: (__) -
  • Cell: (__) -
  • Work: (__) -
• Email: ____________________

Secondary Contact

• Name: ____________________
• Relationship to Child: ____________________
• Phone Numbers:
  • Home: (__) -
  • Cell: (__) -
  • Work: (__) -
• Email: ____________________

Emergency Contacts (Other than Parents/Guardians)

1. Name: ____________________ Relationship: ____________________
   • Phone: (__) -
2. Name: ____________________ Relationship: ____________________
   • Phone: (__) -

Medical Information

• Primary Care Physician: ____________________
• Phone: (__) -
• Preferred Hospital: ____________________
• Insurance Provider: ____________________
• Policy Number: ____________________

Medical History

• Allergies: ____________________
• Current Medications: ____________________
• Chronic Conditions: ____________________
• Previous Hospitalizations: ____________________

Emergency Medical Authorization

I hereby give consent for emergency medical treatment of my child in the event that I cannot be contacted. I understand that this authorization does not cover major surgery unless the medical opinions of two licensed physicians/surgeons concur on the necessity.

Signature: ____________________ Date: //___

Photo/Media Release (Optional)

□ I authorize □ I do not authorize the use of my child's photo for medical documentation purposes.

Signature: ____________________ Date: //___