Emergency Treatment Release Statement: I hereby authorize BHBH staff to render medical treatment to myself/ son/daughter ____________________________, which, in their judgment, is necessary in the event of illness or injury. I understand that I may or may not be contacted regarding this treatment.
_______________________________________________
(Signature of Participant or Parent/Guardian if under 18) (Date)
|
Participant's Name: |
_____________________________________ Date Of Birth: _____________ |
| Address: | ___________________________________________________________ ___________________________________________________________ |
| Home Phone Number: ________________ |
| Father's Contact Number: ________________ Mother's Contact Number: ________________ |
| Name of Person at Emergency #: __________________________________ |
| Additional Contact Emergency #: ________________ |
| Relation to Family: _________________________________________ |
Please list any and all allergies, special medical conditions, special medications, special dietary needs, or health problems with
which BHBH should be aware:
________________________________________________________________________________
Please list any and all medications that participant/minor takes on a regular basis. Include amounts taken, number of daily doses and whether you want this medication to be administered by BHBH or whether they will take it themselves:
________________________________________________________________________________
________________________________________________________________________________
Are there any medications that you know of that are contraindicated for medications participant/minor is currently taking on a regular basis?
________________________________________________________________________________
