Consent for Emergency Medical Treatment

LIC 627C Consent for Emergency Medical Treatment

California DSS LIC 627C emergency medical treatment consent form.

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LIC 627C - Consent for Emergency Medical Treatment

As the client, authorized representative, or conservator, I hereby give consent to the facility named below to provide all emergency medical or dental care prescribed by a duly licensed physician, osteopath, or dentist. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of the individual named below.

Facility Name(Required)

Client/Child Name(Required)

First Last

Medication Allergies

Client/Authorized Representative/Conservator Name(Required)

First Last

Title(Required)

Client

Authorized Representative

Conservator

Parent/Guardian

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Consent(Required)

I consent to emergency medical or dental treatment as described above.

Signature(Required)

Date(Required)

Consent for Emergency Medical Treatment

LIC 627C Consent for Emergency Medical Treatment

LIC 627C - Consent for Emergency Medical Treatment

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