Authorization for Emergency Care

Child's Name:(Required)

First Last

Child's Birthdate:(Required)

Allergies:

Medicine child is allergic to:

What medication is the child currently taking?

Pertinent medical history that would affect emergency care:

Parent Name:(Required)

First Last

Phone (Home):(Required)

Phone (Work or Cell):

Emergency Contact:(Required)

Relationship to child:(Required)

Emergency Contact Phone Number:(Required)

I, the undersigned, authorize Coastal Speech Therapy, Inc. to call for appropriate emergency medical treatment for the child listed above if necessary in my absence.

Signature(Required)

Use your mouse or touch screen to sign.

Date:(Required)

77425

New Patient Forms:
All forms, except those indicated as “optional,” are required for new patients.

Policies and Procedures
New Patient Registration Form
Authorization for Emergency Care Form
Notice of Privacy Practices Form
Authorization for Release of Protected Health Information Form (optional)