Consent for Emergency Medical Treatment
In case of medical emergency, the undersigned authorizes Midnight Farm to provide such medical assistance as they determine to be necessary, including the release of above named person’s records. If the person named above is under 18 years of age, the undersigned authorizes Midnight Farm, acting through the adult on its staff who has actual care, control and possession of the person to consent to medical, dental, and surgical treatment of the person when the above named emergency contacts cannot be reached. The undersigned represents to Midnight Farm that he or she is over 18 years of age or parent/legal guardian and either is not divorced from the other parent,or is divorced from the other parent, but has been authorized by a written court order to give consent to medical and dental care and surgical treatment of the above name person. The undersigned will indemnify and hold Midnight Farm, its officers, members, employees and agents harmless if he or she is not empowered by law to give this consent.
The undersigned authorizes any licensed physician and/or medical facility to provide any medical/surgical care and/or hospitalization for the above named person, including anesthesia, which they determine necessary or advisable, pending receipt of a special consent form from the undersigned.