Grand View Hospital Emergency Room Consent Form

DEAR PARENTS.

You are receiving a permission form for emergency care. As always, for routine or non-urgent care, contact your primary care physician. Please give a copy to the individuals caring for your child in your absence. If a visit to the Emergency Department is necessary in your
absence, the caregiver should bring a copy with them.
Any questions regarding insurance coverage should be directed to your insurance carrier.

THANK YOU!

Grand View Hospital
SELLERSVILLE, PA •
215-453-4674

I hereby give permission to the Emergency Room at Grand View Hospital to treat my son/daughter:

Child's Name

First Name

Last Name

while staying with:

Please read and consent to the following:

I understand this permission covers the average emergency such as sprain, cut bruise, scrape, bump, skin rash, such as impetigo, poison oak or ivy, bites such as bee sting and snake bites, allergic reactions, foreign bodies in eyes or skin, upset stomach, diarrhea, pink eye, minor burns, fevers, diagnostic X-rays, suturing, and the like.

I also understand that in cases of major significance such as fracture, appendectomy, or any illness or injury requiring admission that additional consents will be necessary for treatment and that the hospital will make every attempt to reach me.

My child is allergic to the following drugs:

List all that apply or enter "none."

I give permission for my child to receive tetanus booster (if needed).

Yes

No

His/her last tetanus immunization was

MM

DD

YYYY

Authorization is hereby given to release to the following insurance company any information needed to complete hospitalization claim.

Enter Name of Insurance Company

Please read and consent to the following:

Finally, I understand in cases of acute emergency when hospital personnel have attempted to notify me and are unable to reach me, that this permission form will suffice for treatment until such time as I am able to be reached.

Parent Name

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Grand View Hospital Emergency Room Consent Form

DEAR PARENTS.

THANK YOU!

Grand View Hospital
SELLERSVILLE, PA •
215-453-4674

This Permission is valid for six months only.

You will be asked to sign this form upon Check-in.

Grand View Hospital Emergency Room Consent Form

DEAR PARENTS.

THANK YOU!

Grand View HospitalSELLERSVILLE, PA •215-453-4674

This Permission is valid for six months only.

You will be asked to sign this form upon Check-in.

Grand View Hospital
SELLERSVILLE, PA •
215-453-4674