CONSENT FOR MEDICAL TREATMENT

The Marsh Foundation
1229 Lincoln Hwy., PO Box 150
Van Wert, Ohio 45891
(419) 238-1695

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.