CRMC-West 214 E. 23 St. Cheyenne, WY 82001
CRMC-East 2600 E. 18 St. Cheyenne, WY 82001
Health & Fitness 1620 E. Pershing, Cheyenne, WY 82001

(307) 634-CARE

Medical Treatment of Children

Cheyenne Regional Medical Center has found that many children are brought to the hospital for care when the responsible parent and/or guarantor is not present.

It is Cheyenne Regional Medical Center’s policy to hold financially accountable those people who bring the children to the hospital for services.

Accordingly, if an issue of “guarantor” develops, the grandparent, aunts, uncles, etc. are held financially accountable for charges generated.

In order to alleviate the problem, a form signed by the responsible party is available, and should be presented when the child is brought to the hospital.

Permission To Treat

Date:__________

_______________________________________________

has my permission to sign for medical treatment of my child,

_________________________________________________, (child’s name)

Signature__________________________Relationship to child____________________

Child’s birthdate:____/____/____

Allergies:________________________________________________________________

Current Medications:______________________________________________________

Physician’s Name:______________________________

Last Tetanus Booster:____/____/____

Dentist's Name:________________________________

Pertinent Medical History:__________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

If you would like to have your insurance billed, please attach a copy of the insurance card.

In Case of Emergency, remember to call 911.

Disclaimer - CRMC's core values are to provide quality patient care and outstanding patient satisfaction to all our patients. Part of providing quality patient care and outstanding patient satisfaction is respecting your privacy rights and maintaining the confidentiality of your medical records. For more information on patient privacy please read our patient privacy policy. CRMC will not use or disclose your health information for any purpose not described in this Notice without your written authorization.

Health information provided on Cheyenne Regional Medical Center's web page is intended as a guideline and not as a specific medical protocol. Every actual medical situation - emergency or non-emergency - is unique to each individual, and requires the clinical judgment of a qualified physician. For more information, or clarification, we recommend that individuals contact their personal physician.

Our Web site may include information and other material prepared by other sources. We also link to other Internet sites and resources. This information and links are provided as a courtesy. We are not responsible for the availability, updating, and accuracy of any information provided on these outside sites or for the privacy or security of these outside sites.

The information on this Web site is general in nature and is not intended as a substitute for consultation with a doctor and a particular treatment plan. The material provided is not intended to create, and the receipt of it does not constitute, a doctor-patient relationship. Should you have any health-care-related question, you should contact a doctor and arrange a consultation. Any e-mail generated from this Web site may not be secure and is not intended to create, and the receipt of it does not constitute, a doctor-patient relationship. E-mail communication is not intended as a substitute for consultation with a doctor.