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Consent for Medical & Dental Services
Please read and sign the form below.
Consent for Medical & Dental Services
I,
hereby authorize House of Hope for Girls to obtain medical, dental, and psychiatric care for
as required or medically necessary. I understand that this could include routine and emergency medical and dental examinations, medication management (as prescribed by a physician or psychiatrist), testing, and possible hospitalization. I hereby authorize and consent to any X-ray examination, cleanings, anesthetic, inoculation, vaccination, medical or surgical diagnosis, treatment, and hospital care to be rendered to
while placed at House of Hope Girls Residential Program, under general supervision and upon the advice of a physician, psychiatrist, or dental care provider licensed under the provisions of the
Medical Practice Act in the State of Georgia.
I also hereby authorize any insurance benefits to be paid directly to any hospital or doctor providing care, and I recognize my responsibility to pay for all non-covered services. In addition, I authorize the physician to release any information necessary to process an insurance claim.
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