I, the undersigned, do hereby agree and give my consent for the staff of The Marsh Foundation Child and Family Services to obtain medical, dental and optical care for
This consent includes but is not limited to routine medical or dental examinations and emergency medical treatment, including major operations.
I, the undersigned, do hereby agree and give my consent to any examination, operation or treatment that the attending physicians or assistants may deem necessary or advisable for the above listed youth.
I further agree to assume any expenses for medical, dental, surgical, or hospital care that this youth may incur. Please bill me/agency directly at the following address below:
I further acknowledge that The Marsh Foundation assumes no financial responsibility for
the medical, dental, surgical, or hospital care of the above listed youth.
1229 Lincoln Highway,(P.O. Box 150)Van Wert, Ohio 45891