Pediatric Healthcare Connection - Release

To whom it may concern,

I, the parent/guardian, hereby authorze the agency, to seek emergency medical treatment for my child should the need arise. I agree that I will at all times provide agency with phone numbers or other information necessary to quickly contact me in such emergency situations. I release the agency of any liability for medical treatment that my child may receive from other medical personnel while in the care of agency emplyee. I further realize that circumstance beyond the control of the agency may arise that may pose a threat of danger or cause harm to my child and I release the agency and the employee from any liability related to these circumstances.


Special medical conditions or drug allergies that emergency medical personnel should be aware of regarding my child.


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