New Haven Youth & Family Services
Medical Release & Consent for Treatment
Youth Name: ___________________________________
Date of Birth: ___________________________________
Consent for Treatment
I hereby authorize and give my consent for medical and dental care to be provided to the above named minor while he is on any property and/or activity owned, operated, or supervised by New Haven Youth & Family Services, Inc. Medical and dental care shall include but is not limited to:
- Routine admission and placement examinations including blood tests, urinalysis, immunizations, and other tests deemed medically necessary by the attending physician.
- Radiographic or laboratory examinations, drug screening (including blood and/or urine tests), anesthesia, medical or surgical diagnosis, or treatment and hospital care to be rendered under the general or specialized supervision and upon the advice of a physician and/or surgeon licensed under the provisions of the Medical Practice Act or by a dentist licensed under the provisions of the Dental Practice Act.
- Psychotropic medication, Psychiatric assessment and care, and Counseling and Psychological treatment as necessary.
It is understood by me that in the case of serious illness or accident, a reasonable effort to contact me or my representative will be made before medical or dental treatment is commenced, if time and conditions permit. However, in cases of immediate emergency or if New Haven Youth & Family Services, Inc. cannot locate me with reasonable diligence, I hereby authorize and appoint as my Attorney in Fact, the administer or representative of New Haven Youth & Family Services, Inc to arrange for and to consent to such medical and dental treatment as recommended by a licensed physician or dentist.
Release from Responsibility
I further agree to hold harmless the administrator of New Haven Youth & Family Services, Inc, or any adult acting as agent, from any liability arising out of use of or reliance on this document.
Release of Information
I further authorize any health care provider to release to New Haven Youth & Family Services, Inc., all information and records in their possession concerning all medical, psychiatric, or dental treatment or examinations rendered to the above named minor rendered in the past or during the period the minor is the care of New Haven Youth & Family Services, Inc.
Responsibility for Payment
I assume responsibility for all costs associated with the services provided including medications, which are not covered by health insurance and understand that all demands for payment of uncovered costs will be sent to me
Allergies/Reactions to Medications
Known allergies and/or reactions to medications:
Signature of Parent, Guardian, or Authorized Representative/ Date
Signature of NHYFS Representative or Witness/ Date