Consent For Emergency Medical Treatment

_____________________________________________ do hereby consent to any x-ray, examination, anesthetic, medical or 

Name of Minor

surgical diagnosis, or treatment and hospital service that may be rendered to 

_____________________________________________under the general or special instructions of

Name of Minor

_____________________________________________ or physician named by Anasazi, when the need for such treatment is 

Name of Physician                    Telephone number

clear and when efforts to contact me are unsuccessful, whether such diagnosis or treatment is rendered at the office of a physician or at a licensed hospital.

It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage Anasazi and said physician to exercise their best judgment as to the requirements of such diagnosis or treatment.  This consent shall remain effective until the Client is discharged from Anasazi, unless sooner revoked in writing and delivered to said physician or said persons entrusted with the custody of said minor.

PARENT/LEGAL GUARDIAN SIGNATURE FIELD

PARENT/LEGAL GUARDIAN SIGNATURE FIELD

Anasazi REPRESENTATIVE SIGNATURE FIELD