Medical Waiver

In case of medical emergency, I hereby authorize the listed physicians and/or their designated associates or assistants, or their covering physicians, or in the event these persons cannot be contacted, the emergency physician on duty at the hospital to provide emergency treatment to our child for:

A: Any laceration, fracture or other traumatic injury; or

B: Any symptom, disease, or injury which in the judgment of the attending physician, if untreated reasonably may be expected to increase the risk or threaten disfigurement or impairment of his/her facilities.

No surgery of life threatening procedures may be performed on my child and no general anesthesia may be administered unless:

A: The life or health of my child is in danger, or if delaying such treatment to obtain consent would create a threat or serious injury to the health of my child.

B: The attending physician and one other physician consult and agree that such treatment is necessary for the health of my child.