Medical consent

Medical Consent Form
Parent/Guardian work phone___________________________ Emergency and Health Information
Does youth have . . . (if “yes” please explain)
_____yes _____no
Allergies? ___________________________________________________________ Heart condition? ______________________________________________________ Other? ______________________________________________________________ Is youth subject to . . . (if “yes” please explain)_____yes _____no Fainting? ___________________________________________________________ Sleep walking? _______________________________________________________ Upset stomach? ______________________________________________________ Motion sickness? _____________________________________________________ Other? ______________________________________________________________ Does youth have a reaction to . . . (if “yes” please explain)_____yes _____no Bee sting? ___________________________________________________________ Penicillin? __________________________________________________________ Other drugs? _________________________________________________________ Poison ivy, oak, sumac? ________________________________________________ Other? ______________________________________________________________ Please indicate anything else leaders should know to help avoid or deal with your youth’s health.
________________________________________________________________________________________________________________________________________________________________________________ Date of last tetanus shot _______________________Insurance Co. _______________________________________ Policy # __________________________Name of policy holder ____________________________________________________________________Pre-cert: _____yes _____no If yes, phone number _____/_____-_______Doctor’s name _________________________________________ Phone _____/_____-_______You have permission to give my youth: ___yes ___no robitussin (cough medication) ___yes ___no solarcaine spray/lotion/ointment Emergency procedure: in the event of any emergency leaders will attempt to first contact parent/guardian/doctor! If
this is not possible, note below:
___yes ___no
1. With my signature I hereby authorize First Aid by staff or youth workers.
2. With my signature I hereby authorize emergency medical care by hospital staff and or doctor selected by church 3. With my signature I hereby authorize doctor selected by church staff or youth worker to hospitalize, secure treatment for, and to order injection, anesthesia, blood transfusion or surgery.
If parent/guardian has answered “NO” to any of the above, parent/guardian must indicate procedure to be followed in
the event that parent/guardian is unable to be contacted.


Microsoft word - new patient history form.doc

Full Name:______________________________________________ Address: _______________________________________________________________________ Suburb: ________________________________________________ Telephone No. (H): ___________________(W)_________________ (M) ____________________ Email address: __________________________________________________________________ No. of hours you work each week:

Jiaogulan neu

ist auch mit zahlreichen klinischen Studien belegt. Diese Studien zu zitieren ist aber oft ein rechtliches Adaptogene sind Natursubstanzen, die dem Körper Problem – Jiaogulan ist kein Heilmittel und darf, wie dabei helfen, sich an Stresssituationen anzupassen so vieles aus der Natur, nicht mit Wirkungen in und einen positiven Effekt bei stressinduzierten Zusammenhang gebracht werden. Aus

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