Parental Consent Form

If you’re traveling and have to leave your children in the care of someone else, be sure they’re protected. Always leave written authorization so your children can receive emergency medical treatment, if needed. For your convenience, Dupont Hospital has provided a link for a downloadable Parental Consent Form. Simply download the form below, fill it out, and leave it with your children’s caregiver. You’ll need a separate, dated form for each child each time you leave town.

Click here to download and print the Parental Consent Form.

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LUTHERAN HEALTH NETWORK
BLUFFTON REGIONAL MEDICAL CENTER | DUKES MEMORIAL HOSPITAL | DUPONT HOSPITAL* | KOSCIUSKO COMMUNITY HOSPITAL*
LUTHERAN HEALTH PHYSICIANS | LUTHERAN HOSPITAL* | MEDSTAT | THE ORTHOPEDIC HOSPITAL* | REDIMED | REHABILITATION HOSPITAL*
ST. JOSEPH HOSPITAL*

*A physician owned hospital.

If you are experiencing a medical emergency, call 911.
*ER wait times are door to clinical professional and can change quickly depending on the urgency of patients that arrive by ambulance. Lutheran Health Network provides care to patients with life-threatening illnesses first.
Patients are seen in order of severity, therefore, your spot may not be guaranteed. In case of a life-threatening emergency, call 911.
Dupont Hospital is owned in part by physicians.
Patient results may vary. Consult your physician about the benefits and risks of any surgical procedure or treatment.