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: *
I hereby give permission to the Emergency Room at Grand View Hospital to treat my son/daughter:
Child's Name
Please read and consent to the following: *
List all that apply or enter "none."
I give permission for my child to receive tetanus booster (if needed). *
His/her last tetanus immunization was
His/her last tetanus immunization was
Enter Name of Insurance Company
Please read and consent to the following: *
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone

This Permission is valid for six months only.

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