Authorization for Emergency Medical Treatment Form

Participant:vvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvv
Age:
Height:
Weight:
Date of Birth:
Male:
Female
 
Phone:
Physician's Name:
Health Insurance Company:
Address:
Allergies to medications:
Current medications:
 

In the event of an emergency, contact:

Name: Relation: Phone:
Name: Relation: Phone:
Name: Relation: Phone:
 
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or
while being on the property of the agency, I authorize Jacobs' Ladder Therapeutic Riding Center to:
 
1. Secure and retain medical treatment and transportation if needed.

2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

 
Consent Plan
This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person(s) above is unable to be reached.
 
I Accept
 
I Do NOT Accept
 
Non-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:
 
 
 
Therapeutic and Safety Issues
Check and describe applicable issues (indicate current or history of):
inattention
hyperactivity
lack of concentration
learning disabilities
developmentally delayed
mentally challenged
boundary issues
social skills problems
problem with peers
separation anxiety
anxiety
phobias
aggressive
assaults
manipulative
unpredictable or dangerous behavior
sensory impairment
sensitivity, preferences
tics or stereotypic behavior
psychosomatic symptoms
medical issues
self-injurious behavior
suicidal tendencies
history of runaway
issues of parental support
issues of family support
sexual abuse/acting out
history of physical abuse
emotional abuse
hallucinations
delusions
illusions
dissociations
substance abuse problems
legal problems
school problems
history of animal abuse and/or fire setting
seizure disorder
possible medication side effects
 
 
Contact--Leslie Jacobs--(229)794-1188-- leslie_j@hotmail.com