Application For Treatment

APPLICATION No.: ____________HOSPITAL No.: ______________CODE No.: ___________

PLEASE PRINT

Childs Last Name______________________________ First Name______________________________

Childs Address ________________________________________________________________________

______________________________________________________________________________________

Telephone No. (Home)_(____)________________ Telephone No. (Work) _(____)_________________

Telephone No. (Other)_(____)________________ Sex ________ Place of Birth__________________

Date of Birth _____________________ Health Insurance No __________________Exp Date________

Name of Father ________________________________________________________________________

Maiden Name (including first name of mother) _____________________________________________

Legal Guardian of Child ________________________________________________________________

Legal Guardian Address ________________________________________________________________

______________________________________________________________________________________

Telephone No. (Home)_(____)________________ Telephone No (Work) _(____)__________________

Montreal Hospital Chart No. ______________Ste Justine’s Hospital Chart No. ___________________

FOR HOSPITAL USE ONLY RESUME OF MEDICAL RECORDS REQUESTED YES __ NO __

Diagnosis & Clinical Data: (For use by referring physician)

SECOND OPINION YES ___ NO ___

Referring Physician ____________________________________________________________________

Address of Referring Physician ___________________________________________________________

______________________________________________________________________________________

Attending Physician ____________________________________________________________________

Referring Shriner _____________________________ Phone No.: _(____)________________________

Referring Shriner Address _______________________________________________________________

______________________________________________________________________________________

NOTE : Please attach Consent Form and Check List to Application

CONSENT FOR CLINIC, TREATMENT and / or INVESTIGATIONS

1. CONSENT TO TREATMENT

I, _______________________________ hereby consent to, authorize and request the attending physician or physicians of the Shriners Hospitals for Children, Canada, to perform the necessary treatment and / or investigations to _________________________.

2. CONSENT TO ANAESTHETIC

I hereby consent to, authorize and request the administration of such local anaesthetics as may be considered necessary by the physician.

3. CONSENT TO PHOTOGRAPHS AND VIDEOS

I hereby consent to and authorize the taking of photographs or the filming of videos with the understanding that the same are to be used for medical, educational or scientific purposes.

4. I understand that this is a University Affiliated Hospital. This may involve the child’s illness and his/her treatment being explained to doctors-in-training and hospital Staff Trainees. Also, the child may be examined and treated by them under the direction of senior members of the Hospital staff, and I give my consent thereto.

I agree that I have read and fully understand the above consent, that all statements requiring completion were completed prior to my signing, and that all deleted or added paragraphs have been initialled by me.

Date ___________ Legal Guardian _____________________Witness ______________

Date ___________ Patient over 14 years old ______________ Witness ______________