Key Documents

Documents will be posted here as needed.

Patient/USC Program Participant Information
Please enter full legal name:
Last Name:

First Name:

Middle Name:

What is your child’s preferred name?:

Please enter your local home address:
Street:

City:

State:

Please enter your preferred phone number (include area code):

What type of phone number was that?
Cell:

Home Phone:

Please enter your child’s date of birth:

Please select your child’s gender:
Male:
Female:
Other:
When will your child be at CS@SC:
From:
To:
Is your child under 18 years of age?:
Yes:

No:

Cailfornia Family Code 6910 expressly provides that a parent or legal guardian may authorize an adult or entity into whose custody a child is entrusted to consent to necessary medical treatment. In the best interest of your child, the Engemann Student Health Center seeks such written autorization.

Please print the name of a parent or legal guardian:

Please write the child’s mother’s maiden name:

Consent by an adult (over 18) participant or legal custodian

1. General Consent for Treatment. I voluntarily consent to and authorize the Engemann Student Health Center (ESHC) to administer routine medical care and treatments, which may include, but is not limited to physical examination, diagnostic tests, medical procedures and medications as deemed necessary or advisable by an ESHC clinician. I understand and agree that I might recieve care from a physician who does not hold a physician’s and surgeon’s certificate but who is qualified and certified by the California Medical Board to provide care in a special program as a visiting professor or faculty member. Ii am aware that the practice of medicine is not an exact science, and I acknowledge the ESHC makes no guarantee to me as to the result of tests, examinations, treatments, procedure or any other services rendered.
2. Rights and Responsibilities. I have been made aware of my rights and responsibilities as posted in the ESHC waiting areas and website. These responsibilities include but are not limited to: personal financial responsibility for any charges not covered by insurance or the USC Student Health Fee, followign provider prescribed treatment plan, participating in care, behaving respectfully during visit and the right to change provider if other qilified providers are available.
Signature:
What is your relationship to the participant:
Self:
Parent:
Legal Custodian:
Other:
If other was chosen, please specify your relationship to the child:

What is today’s date?:

Emergency Contact (Must be a relative or a friend who is over the age of 18)