Pediatric Emergency Care Consent Form

Emergency Consent Form

If you are unavailable, an emergency consent form allows you to provide consent for your child’s emergency care. Protect your child by leaving this form with your babysitter, day care center or temporary guardian. In the event of a medical emergency, the form should accompany your child to the hospital.

For life-threatening emergencies

Call 911

Doernbecher Emergency Room

3181 S.W. Sam Jackson Park Road
Portland, Oregon  97239