Parental Consent Form

If you're traveling and have to leave your children in the care of someone else, be sure they're protected. Always leave written authorization so your children can receive emergency medical treatment, if needed. For your convenience, Lutheran Hospital has provided a link for a downloadable Parental Consent Form. Simply download the form below, fill it out, and leave it with your children's caregiver. You'll need a separate, dated form for each child each time you leave town.

Click to view and print the Parental Consent Form.
(To view the Parental Consent Form, you'll need the free Adobe Acrobat Reader.)

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LUTHERAN HEALTH NETWORK
BLUFFTON REGIONAL MEDICAL CENTER | DUKES MEMORIAL HOSPITAL | DUPONT HOSPITAL* | KOSCIUSKO COMMUNITY HOSPITAL*
LUTHERAN HEALTH PHYSICIANS | LUTHERAN HOSPITAL* | MEDSTAT | THE ORTHOPEDIC HOSPITAL* | REDIMED | REHABILITATION HOSPITAL*
ST. JOSEPH HOSPITAL*

*A physician owned hospital.

If you are experiencing a medical emergency, call 911.
*ER wait times are door to clinical professional and can change quickly depending on the urgency of patients that arrive by ambulance. Lutheran Health Network provides care to patients with life-threatening illnesses first.
Lutheran Hospital is owned in part by physicians.
Patient results may vary. Consult your physician about the benefits and risks of any surgical procedure or treatment...