This information is approved and/or reviewed by U-M Health System providers but it is not a tool for self-diagnosis or a substitute for medical treatment. You should speak to your physician or make an appointment to be seen if you have questions or concerns about this information or your medical condition. Exención de responsabilidad en Español | Complete disclaimer
I (we)_____________________________________________________________
Name(s) and address(es) of parents
designate to _______________________________________________________
Name and address of designee
the power to consent in our absence to medical care for our
child(ren):
_________________________________ _______________________________
Name(s) and age(s) of child(ren)
_________________________________ _______________________________
Parent(s)' phone number: __________________________________________
Child(ren)'s physician(s): ________________________________________
Physician's address and phone number: _____________________________
___________________________________________________________________
Medical insurance company: ________________________________________
Policy #: _________________________________________________________
Dates of expected absence from ________________ to ________________
CHILD(REN)'S MEDICAL HISTORY
Chronic conditions________________________________________________
Medications that need to be given on a regular basis:
___________________ __________________________________________
Child's Name Medication name, dosage, frequency
___________________ __________________________________________
Child's Name Medication name, dosage, frequency
___________________ __________________________________________
Child's Name Medication name, dosage, frequency
Allergies:________________________________________________________
Dietary or other restrictions: ___________________________________
