LIC 627 Consent for Emergency Medical Treatment
State of California – Health and Human Services Agency California Department of Social ServicesLIC 627 (9/08) (CONFIDENTIAL)
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
Technique Adventure & Activity Center
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.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:
PARENT OR AUTHORIZED REPRESENTATIVE
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Signed by Kathy Olvera
Signed On: January 9, 2021
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Document Name: LIC 627 Consent for Emergency Medical Treatment
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