Born on ___________________, do hereby give my consent to
_________________________________________, to secure and authorize such emergency medical treatment as the above name might require while under the supervision of said care provider. I also agree to pay all the costs and fees contingent on emergency medical care or treatment for this person as secured or authorized under this consent.
NOTE: Every effort will be made to notify the parents/ son/ daughter/ guardian, etc. in case of an emergency. In the even of an emergency, it would be necessary to have the following information:
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