Form Lic 627C at a glance
What it is: Consent for Emergency Medical Treatment, Adult and Elderly Residential Facilities, is a form of the State of California Health and Human Services Agency, California Department of Social Services, Community Care Licensing.
Who signs: The client, authorized representative or conservator gives consent.
A filled-in Form Lic 627C example: a client completes the emergency consent
How to fill out Form Lic 627C, box by box
Facility name and name
Write the FACILITY NAME on the line to provide all emergency medical or dental care.
Write the name of the individual after FOR: the care is prescribed by a duly licensed physician (M.D.), osteopath (D.O.) or dentist (D.D.S.), and this care may be given under whatever conditions are necessary to preserve the life, limb or well being of the individual named.
Medication allergies, date and signature
Enter the medication allergies of the client.
Enter the date and the client, authorized representative or conservator signature, and circle the appropriate title.
Home address, home phone and work phone
Write the home address under HOME ADDRESS.
Enter the home phone and the work phone.
Sources
[1] Form Lic 627C (4/00), Consent for Emergency Medical Treatment, Adult and Elderly Residential Facilities, California Department of Social Services (the Official source link on this page).
