Form LIC 627 Consent for Emergency Medical Treatment - Child Care Centers or Family Child Care Homes - California

Form LIC627 or the "Consent For Emergency Medical Treatment" is a form issued by the California Department of Social Services.

The form was last revised in September 1, 2008 and is available for digital filing. Download an up-to-date Form LIC627 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Child Care Centers Or Family Child Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
_________________________________________ TO OBTAIN 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
NAME
WHATEVER 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 627 (9/08) (CONFIDENTIAL)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Child Care Centers Or Family Child Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
_________________________________________ TO OBTAIN 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
NAME
WHATEVER 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 627 (9/08) (CONFIDENTIAL)
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