• Medical Consent and Information Form

    Medical Consent and Information Form

    Summit County Court of Common Pleas Juvenile Division
  • Juvenile Information

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  • Physician Information

  • Insurance Information

  • Medical Information

  • Consent for medical treatment/authorization to release medical information

    I hereby grant permission for such medical and/or psychiatric treatment and procedures as are necessary in the physical and/or mental examination, diagnosis and treatment of above named juvenile. As the parent or legal guardian, I agree to allow a hospital, physician, psychiatrist, nurse, or provider retained by the Detention Facility to provide medical and or psychiatric care and/or treatment when medically necessary and to provide any clinic hospital, physician, psychiatric or health agency with the appropriate medical or mental health information for the above named juvenile.

    I hereby grant permission to Akron Children's Hospital to provide emergency medical treatment if they are unable to contact a parent or legal guardian or until the parent or legal guardian can be present at the hospital.

    I hereby grant permission to any clinic hospital, physician, psychiatric or health agency to release the detention facility and/or the detention facility physician or psychiatric any information pertaining to the health or previous medical or psychiatric care of the above named juvenile

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