Emergency Treatment Form


As the parent or authorized representative, I hereby give consent to Center for Developing Kids Inc., to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.), osteopath (D.O.), or dentist (D.D.S.) for *. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of the child named above.

My affixed signature testifies that I am the parent/authorized representative of the child named on this document. Further, I will be responsible for the charges for any medical or dental treatment or hospitalization rendered by reason of this authorization.

Center for Developing Kids would prefer that you stay on the premises while your child is receiving therapy. If you need to be away, you must leave a number on the contact sheet.

Please sign below.*