While You Are Away

If you are going away for business

or pleasure, you have probably
made arrangements for your child
while you are away. The Sullivan
County Community Hospital would
like to assist you with those plans
by providing a pre-consent form for
treatment and medical information.
Leaving this information with those
responsible for your children will
help you feel more secure should
your child become ill or injured
while you are away.

The mission of Sullivan County

Community Hospital is to provide
exceptional care and improve the
health of our community.

Pre-Consent
Form for
Emergency Care

Presenting this
completed form means your
child can be treated more
quickly when you cannot be
located.

Before You Leave

Fill out a form for each of your

children.
Update the information every
time you go away.
Leave the completed form with
the person responsible for your
children in your absence.
Instruct those responsible to
take this form with him/her in the
case of a medical emergency.

Presented By:
Phone: 812-268-4311

Website: schosp.com
Sullivan County
Community Hospital
2200 North Section Street
P.O. Box 10
Sullivan, Indiana 47882-0010

Authorization for
Treatment of Minor
I, _________________, being the
parent or legal guardian of
__________________, give my
consent for emergency medical and
surgical treatment of this minor in
a licensed hospital by a licensed
physician should his/her condition so
require it in my absence. I understand
that in such a case reasonable attempts
would be made to contact me, time and
conditions permitting.
As long as the medical or surgical
treatment considered is necessary in
the situation and is in accordance with
generally accepted standards of
medical practice for the particular type
of injury or illness involved, I impose no
specific limitations or prohibitions
regarding treatment other than the
following (If none, so state): ________

_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
This authorization is effective for the
following time period: ___________
_______ to ___________________

____________________________
Parent or Legal Guardian Signature

_____________________________
Printed Name

_____________________________
Date

Information for Emergency Medical Treatment

Please use a separate form for each child.
Last name of child: ____________________
Date of Birth:_________________________

First name: _________________________

Address: ________________________________________________________________
City, State, Zip: ___________________________________________________________
Phone Number: ___________________________________________________________

Fathers Work: _______________________

Mothers Work: _______________________

Phone: _____________________________
Phone: _____________________________

Other Contact Person: __________________

Phone: _____________________________

Medical Information
Family Doctor: _______________________
Preferred Surgeon: ____________________

Phone: _____________________________
Phone: _____________________________

Insurance Information
Carrier: ____________________________
Members Name: _____________________
Account Number: _____________________

Identification Number: __________________

Benefit Code: ________________________

Medical History
Allergies, if any, including medications: ___________________________________________

_______________________________________________________________________
_______________________________________________________________________
Chronic or existing diseases or medical problems (e.g. diabetes, epilepsy): _________________
_______________________________________________________________________
_______________________________________________________________________
Medicines your child is taking now: _____________________________________________
_______________________________________________________________________
_______________________________________________________________________
In an emergency, parents or legal guardians can be reached as follows: __________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________