Emergency Care

Emergency Care

Dukes Memorial Hospital provides emergency service right in your neighborhood where and when you need them. Our Emergency Room is staffed by full-time emergency room physicians. If you need more advanced care, ground and air transportation is just a phone call away with the Lutheran Hospital Critical Care Transport Team.

Emergency Consent for Minors

Accidents or sudden illness involving children and adolescents under 18 can occur at any time and place. Unfortunately, many times parents or guardians are not available to give hospital emergency staff important health information about their child and the legal permission needed to provide the necessary medical treatment.

The attached pre-consent form enables healthcare professionals to treat your child for minor emergencies when, and only when, you cannot be notified. The form not only provides permission but also provides valuable health facts about your child. You can also use the form to inform hospital staff about special things that will help comfort your child. The form should be completed and given to your child’s caregiver during times when you are not available, including times when your child is going to camp or traveling with someone else. You should also keep a copy of the completed form(s).

Of course, if an emergency is life threatening or one in which the young person might develop complications, treatment would begin immediately, with or without a consent form.

Fill out a form today. You can be comfortable knowing your child will receive prompt, personalized medical attention no matter where you may be in the event of an emergency.

Emergency Child Pre-Consent Form
Information for Emergency Treatment

You may type information directly into the form and then print, or you may print a blank form to fill out at a later time. Each child needs his/her own form

Child's Last Name:
First Name:
Nickname:
Date of Birth:
Today's Date:
I, (print name) Check one: parent legal guardian Signature:
Home Address:
City, State, Zip:
Home Phone:
Work Phone:
Authorize healthcare personnel to treat the above named child in an emergency while being cared for by:
Name(s) of Caregiver(s):
Child's Physician:
Medicines your child is taking now:
Allergies, if any, including medications:
Date of last tetanus booster shot:
Chronic or existing diseases or medical problems (diabetes, epilepsy, etc.)
Medical Insurance Carrier:
Identification Number:
Members Name:
Benefit Code:
Account:
Other things that make your child special (pets' names, hobbies etc.):

You are ready to print your form. Don't forget to print an extra copy to keep with your child's healthcare records at home.

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