Fillable PERMISSION FOR TREATMENT (John Brown University)

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PERMISSION FOR TREATMENT (John Brown University)

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BROWSE JOHN BROWN UNIVERSITY FORMS
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Date (MM/DD/YYYY)
MEDICAL/MENTAL HEALTH AUTHORIZATIONS:
PERMISSION FOR TREATMENT
* Consent is given for treatment in the University Student Health Service by licensed personnel for
routine health (physical or mental) care, assessment, treatment, and if necessary, referral or
hospitalization.
* If health care is needed in the absence of a Health Service Personnel, a college representative may
choose local medical personnel on my behalf.
* No guarantee has been made to me as to the results to be obtained by treatment given to me.
* It is understood that the University will contact the designated, authorized person(s) in the case of an
emergency or serious illness (physical or mental).
* I understand that I will be responsible for charges incurred due to illness, injury or accident.
Signed:
Student ID Number
Student Name
(Please Print)
Please print this form, sign, and mail it to : JBU Campus Nurse
2000 West University St.
Siloam Springs, AR 72761
Student Signature
(If over 18 years of age)
Parent or Guardian
(If student is NOT 18 years)
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Completed 23 July 2020

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