For Caregivers
Care Book: Consent to Treat Form
Last Updated:
In the Event of An Emergency
For____________________________
As parent or legal guardian (circle one) for ________________________________,
I give permission for _________________________________ to authorize any medical treatment __________________________________ may need.
This consent is valid from ___________ to ____________, ____________
Date Date Year
_________________________________ ____________________
Signature of Parent or Guardian Date
Printable Forms
Care Book: Consent to Treat Form
Karen Moderow is a freelance writer with over ten years experience working in public relations for charitable organizations. As the parent of a son with traumatic brain injury, she has considerable experience dealing with brain injury issues. Her new book, Back Roads Home, chronicles her family’s journey. She is the Director of Content for the Brain Injury Resource Center. www.moderow.us