Providence Mt Hood Meadows Mountain Clinic Consent to Treat
Providence Health & Services – Oregon dba Providence Hood River Memorial Hospital Mountain Clinic (“Providence”) is a medical
first aid clinic located at Mt. Hood Meadows Ski Resort that provides emergency response and immediate care. For serious injuries
or illnesses, clinic staff will stabilize and transfer patients to an appropriate medical facility.
In case of injury or illness requiring medical intervention, every effort will be made to notify parent/guardian. In the event that this
is not possible, completing and signing the below form authorizes Providence to provide medical treatment to your child. Please
note, that in the case of an emergency situation, parental consent is not needed to provide emergency medical treatment to a minor
child.
STUDENT/PARTICIPANT INFORMATION
Last name
First name
Date of birth
Gender
Home address
Apartment or building number
City
Zip code
Home phone
Student/participant cell phone
Group organizer/group name
Organizer phone
PARENT/GUARDIAN INFORMATION
Last name
First name
Date of birth
Relationship to student/participant
Parent phone (Best contact number)
Parent alternate phone
Parent email address
EMERGENCY CONTACT INFORMATION
Name
Relationship to student/participant
MEDICAL INFORMATION
Medical provider name/phone
Dentist name/phone
Date of last tetanus shot
Allergies (Including medication allergies)
Current medications
Health history (Chronic or existing diseases or medical problems – i.e. asthma or diabetes)
FINANCIAL INFORMATION
Insurance company name
Insurance subscriber ID number
Group/plan number
Subscriber name
Relationship to patient
Subscriber date of birth
Please initial below (All boxes must be initialed and form signed for non-emergent services to be performed):
_____ I consent for my minor child to receive health care services provided by Providence and I affirm that I have the right to consent as the
parent or legal guardian of the minor child listed below.
_____ I authorize Providence and their staff to communicate with my minor child’s healthcare providers about healthcare services rendered by
Providence.
_____ I accept financial responsibility for all treatment provided. The balance is due 30 days from the billing date. If I need financial assistance
or wish to establish a payment plan I can contact a Providence financial representative.
_____ I authorize Providence to bill my minor child’s health insurance provider for healthcare services rendered at Providence.
Medicare and Medicaid enrollees: I request payment of authorized Medicare or Medicaid benefits be made on my minor child’s behalf
for any services furnished to my minor child by Providence.
_____ I am aware that Providence has teaching facilities and that a student may be involved in my care
Parent/guardian name: ________________________________________ Parent/guardian signature ___________________________________
Student/participant name: _____________________________________ Date: _______________________________________