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KID FORMS

online forms

Madison Pediatrics



Emergency Caregiver Consent Form - Update

(Fill. Submit. Done.)



Date: *
CalendarNow


Emergency Care Authorization

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(Type your first and last name.)
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In the event that my child may require medical care (including but not limited to: evaluation, treatment, medication, surgery, and/or transfer to another medical facility) in my absence, I authorize the below listed person(s) to act on my behalf in consenting for such care. I retain full financial responsibility for any care provided.


(Type your first and last name.)


(Type your first and last name.)


(Type your first and last name.)


(Type your first and last name.)
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By signing this form (typed signature), you are certifying the accuracy of this information and agreeing to send the information to Madison Pediatrics, Inc., for inclusion into your child's records.