Where can I find a consent for treatment form?

If you need to bring a child for a primary care or specialty visit, please bring a handwritten note signed by a parent that has custody of the child. In the case of shared custody, it could be signed by either parent. The note should include the patient’s name and birthdate and a phone number where that parent could be reached, if necessary, during the visit.

For an emergency or urgent care visit, bring a letter written by a parent that includes the following information:

• Name(s) and birthdate(s) of child(ren)
• All current medications, including dosages
• Date of last tetanus immunization
• Any known health conditions/concerns
• Any allergies to food or medication
• Name(s), address(es) and phone number(s) of the assigned/temporary caregiver(s)
• Name, address and phone number of child’s/children’s pediatrician/primary care doctor
• Insurance company name with policy and group numbers
• Your preferred hospital or treatment facility (Urgent or Quick Care)
• All phone numbers by which you could be contacted. The hospital will make every attempt to contact you for consent prior to treatment, with the exception of a life-threatening situation
• Parent’s signature and printed name

The assigned/temporary caregiver should have the letter with them when presenting to the hospital, emergency room or urgent care.