Springs Adventist Academy Consent to Treatment

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Email *

Please enter the student's full name (hereinafter referred to as "STUDENT") *

I, the undersigned parent or guardian of STUDENT, a minor, do consent to any medical transportation, emergency examination, anesthetic, medical or surgical diagnosis or treatment and hospital services that may be rendered to STUDENT under instruction of the attending physician. It is understood that reasonable effort will be made to contact the parent or guardian or other emergency contact listed below. It is also understood that this consent is given in advance of any specific diagnosis or treatment being required but is given to encourage Spring Adventist Academy and said physician to exercise his best judgment as to the requirements of such diagnosis or treatment. I also understand that I consent to transportation of STUDENT by the school or an ambulance in the case of an emergency. This consent shall remain in continuous effect until revoked in writing to the school entrusted with the said custody of STUDENT. A photocopy of this authorization shall be considered as effective and valid as the original. Please enter your full name below; your typed signature indicates your understanding and acceptance of this document. *

Today's Date *

YYYY

Parent/Guardian Contact Telephone Number *

Student's Birth Date *

YYYY

Insurance Company *

Insurance Policy/ID Number *

Insurance Group Number *

Name of Preferred Physician *

Phone Number of Preferred Physician *

Name of Dentist *

Phone Number of Dentist *

Please list all student allergies *

Please list any medications student is currently taking *

Please list, if any, student's physical handicaps *

Please list any other relevant information

Additional Emergency Contact: Full Name, Relationship to the Student, and Phone Number

A copy of your responses will be emailed to the address you provided.

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