Form LIC627B "Consent for Emergency Medical Treatment - Children's Residential Facilities" - California

What Is Form LIC627B?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2008;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LIC627B by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form LIC627B "Consent for Emergency Medical Treatment - Children's Residential Facilities" - California

Download PDF

Fill PDF online

Rate (4.4 / 5) 73 votes
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Children’s Residential Facilities
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
_________________________________________ TO PROVIDE ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________. THIS CARE MAY BE GIVEN UNDER WHATEVER
NAME
CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED
ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE
PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE
HOME ADDRESS
HOME PHONE
WORK PHONE
(
)
(
)
LIC 627B (9/08) (CONFIDENTIAL)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Children’s Residential Facilities
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
_________________________________________ TO PROVIDE ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________. THIS CARE MAY BE GIVEN UNDER WHATEVER
NAME
CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED
ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE
PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE
HOME ADDRESS
HOME PHONE
WORK PHONE
(
)
(
)
LIC 627B (9/08) (CONFIDENTIAL)