Waivers

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These waivers are free to you. There is no guarantee to the legality of these waivers. Each state has separate legal standards. They are general waivers. Please copy and paste.

1. Medicine Consent Form
I____________________________________(name of parent) give permission for __________________________ (Newborn Care Specialist) to give my child _____________________(Name of the child) the following medication _____________________for ___________________ (reason) for taking medication).
The dosage for this medication is____________________________(dosage) to be given every _________ (frequency). The last dose was administered today at:_____________ Side effects to watch out for may include: (List all of the possible side effects):

This medicine was prescribed by: _______________________________(Name of Doctor)

Signature of Parent__________________ Date______________


2. Authorization to Treat a Minor:

https://e4k.berkeley.edu/wp-content/.../Medical-Treatment-Authorization-Form.pdf

The Parents will sign and date two “Authorization to Treat a Minor” cards per child: one to be put on file at their pediatrician’s office, the other held in the Newborn Care Specialist’s possession.

In the unlikely event of an emergency, if the Parents cannot be reached by the NCS, the Doctor and/or the Hospital, it allows the Doctor to ask permission of the NCS to administer any medically necessary care to the child(ren). If the NCS is required to give authorization to medical personnel to treat the child(ren), the Parents understand that all medical care administered would be on the advice and at the discretion of medical personnel only, and the NCS cannot be held liable/responsible for the decisions made by said medical personnel. Furthermore, the NCS cannot be held liable/responsible for any medical bills incurred by such medical attention.

Medical Treatment Authorization Form

Minor Full Legal Name: _______________________________________________ Home Address: __________________________________ Date of Birth:______________________________ Gender: Female___________Male___________ Information for Medical Treatment Physician’s Name and Location of Practice: ________________________________________________________________________________________________Physician’s Phone # (if known): (____)________________ Medical Insurer/Health Plan: __________________________ Policy #: ______________________ Allergies to Medications: _____________________________________________________________ Allergies (Other): ___________________________________________________________________ Please note all conditions for which the child is currently receiving treatment: _________________________________________________________________________________ Note any other significant medical information:
_______________________________________________________________________________ AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for _________________________________________ (hereafter “Designated Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care.

It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

This authorization is effective through: ____________________. Signed this _____day of________, 20__.

Parent / Legal Guardian Signature: ________________________Printed Name: _____________________

Witness Signature: _____________________________________ Printed Name:_____________________

3. General Waiver of Liability Form – you will fill in your type of newborn issue i.e.: not wanting to swaddle, rock and play sleeping, tummy sleeping, etc.

Child’s Legal Name___________________________________ Age_________

Parent’s or Guardian name______________________________

I (Your name)_____________________________________ advocate swaddling a baby and sleeping a baby on their back (or whatever you need a waiver for) as per the American Association of Pediatrics to reduce the incidence of SIDS.
• Always place your baby on his or her back for every sleep time.
• Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep.
• Keep soft objects or loose bedding out of the crib. This includes pillows, blankets, and bumper pads.

(back up your advice with scientific research as shown above)

I acknowledge the potential problems that can develop and the risks involved as a result of allowing my child to ____________ defined in the___________(where you found your research)

I waive, release, and discharge the ______________________ ( your name) from any and all liability should the aforementioned action lead to __________( infant child’s name) death, disability, personal injury or claims of any nature which may hereafter accrue my child as a direct or indirect result of participating in ______________________;

b) Indemnify and hold harmless ____________________(your name) from and against any and all claims of any nature including all costs, expenses, and fees arising out of or as a result of _________________, as well as all claims or rights of action for damages which the infant child has or may hereafter have, either before or after he/she reaches his/her majority.

I waive, release, and discharge the ______________________ ( your name) from any and all liability should the aforementioned action lead to __________( infant child’s name) death, disability, personal injury or claims of any nature which may hereafter accrue my child as a direct or indirect result of participating in ______________________;

b) Indemnify and hold harmless ____________________(your name) from and against any and all claims of any nature including all costs, expenses, and fees arising out of or as a result of _________________, as well as all claims or rights of action for damages which the infant child has or may hereafter have, either before or after he/she reaches his/her majority.

___________________ ______________

Your client’s name Date

___________________ ______________