Advocate Christ Medical Center
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Teen Volunteer Consent for Treatment

Emergency Department – 708.684.5360

Advocate Christ Medical Center feels that it is very important to begin treatment on injuries or diseases as soon as possible. In the event your child is brought to our emergency department and we are unable to contact you, this form will help us begin treatment and diagnostic testing. The emergency staff will still attempt to contact you to get personal permission to treat.

Read the entire form and complete all areas. Place your family’s last name at the top of the consent form. Relative/Friend should be someone you feel could give us more information about your child or tell us how to get in contact with you. If you require more room to write Allergies or Special Information, please use the back of this form.



* Indicates required information
Parent/Guardian name(s) * 
Family’s Last Name * 
Email Address * 
Street Address 
City 
State 
Zip Code 
Home Phone 
Cell Phone 
Work Phone 
First Child 
First name 
Middle initial 
Date of birth (MM/DD/YYYY) 
Allergies or special information 
Second Child 
First name 
Middle initial 
Date of birth (MM/DD/YYYY) 
Allergies or special information 
Third Child 
First name 
Middle initial 
Date of birth (MM/DD/YYYY) 
Allergies or special information 
Forth Child 
First name 
Middle initial 
Date of birth (MM/DD/YYYY) 
Allergies or special information 
Other Information 
Relative/Friend to contact 
Phone number 
Family physician 
Phone number 
Authentication * 

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