Form #7 State of New Jersey Departmenent of Human Services Division of Developmental Disabilities EMERGENCY CONSENT FORM ADULT DAY SERVICES In my capacity as the legally appointed guardian of (print name of individual) I hereby consent to any and all medical or surgical treatment, including hospital admission, examinations and diagnostic procedures, anesthetics, transfusions and operations, which, in the event of an emergency are deemed necessary by competent medical clinicians to save the life or preserve the health of the above named individual. I also approve the release from the case records of any medical history or other medical data, which would be necessary for the physician and/or hospital to administer the treatment. It is understood that general consent is only applicable specifically and exclusively to emergency situations. In each and every other instance of elective medical and / or surgical treatment recommended by medical professionals, and explicit, individual consent must be requested within a reasonable advance time period. Emergency treatment should be followed by prompt notification of the guardian by the person(s) responsible for care of the individual. _______________________________________ __________________ Signature of Legal Guardian or individual if own guardian Date _______________________________________ Print Name Copied to: Central file________________
Form #7 State of New Jersey Departmenent of Human Services Division of Developmental Disabilities EMERGENCY CONSENT FORM ADULT DAY SERVICES In my capacity as the legally appointed guardian of (print name of individual) I hereby consent to any and all medical or surgical treatment, including hospital admission, examinations and diagnostic procedures, anesthetics, transfusions and operations, which, in the event of an emergency are deemed necessary by competent medical clinicians to save the life or preserve the health of the above named individual. I also approve the release from the case records of any medical history or other medical data, which would be necessary for the physician and/or hospital to administer the treatment. It is understood that general consent is only applicable specifically and exclusively to emergency situations. In each and every other instance of elective medical and / or surgical treatment recommended by medical professionals, and explicit, individual consent must be requested within a reasonable advance time period. Emergency treatment should be followed by prompt notification of the guardian by the person(s) responsible for care of the individual. _______________________________________ __________________ Signature of Legal Guardian or individual if own guardian Date _______________________________________ Print Name Copied to: Central file________________
ann%20001%20annual%20info%20packet.docx