Medical Consent

- Email*
  
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- Who is the Parent/Guardian giving their permission/consent?
- Personal Title:
- Name:
- Relationship to Child(ren):
- Parent/Legal Guardian Signature
- Draw Signature
- Upload Signature
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  Max. file size: 2 MB, Max. files: 1.
- What address does the parent or guardian have?
- Address
- City:
- State:
- Zip Code
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- How can you get in touch with the parent/guardian?
- Primary Phone Number:
- Alternate Phone Number:
- Email Address:
- When will you sign this medical consent form?
- Date
  MM slash DD slash YYYY
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- For which child is this medical form being created?
- Child Name:
- Date Of Birth:
  MM slash DD slash YYYY
- Where is the address of the child?
- Address:
- City
- State
- Zip Code:
- What phone number does the child have?
- Phone Number(If Applicable):
- For the child's medical records, kindly submit the information below.
- Enter below any known allergies that the child may have:
- Enter below any known medical conditions the child may have:
- Enter below any medications the child is currently taking:
- Should this medical consent form also apply to a second child?
- Include a second child?:
  - Yes
  - No
- Name:
- Date
  MM slash DD slash YYYY
- What is the address of this Child?
- Address:
- City
- State:
- Zip Code:
- What phone number does this child have?
- Phone Number (if applicable):
- For this Child's medical records, kindly supply the information below.
- Enter below any known allergies that the child may have:
- Enter below any known medical conditions the child may have:
- Enter below any medications the child is currently taking:
- Should this medical consent form cover a third child?
- Include a third child?:
  - Yes
  - No
- Child Name:
- Child Date of Birth:
  MM slash DD slash YYYY
- What is the address of this child?
- Address:
- City:
- State:
- Zip Code
- What is the contact information for this child?
- Phone Number (if applicable):
- Please supply the following medical details for this child.
- Enter below any known allergies that the child may have:
- Enter below any known medical conditions the child may have:
- Enter below any medications the child is currently taking:
- Should this medical consent form cover a Fourth child?
- Include a fourth child?:
  - Yes
  - No
- Child Name:
- Child Date of Birth:
  MM slash DD slash YYYY
- What is the address of this child?
- Address:
- City
- State:
- Zip Code:
- What is the contact information for this child?
- Phone Number (if applicable):
- Please supply the following medical details for this child.
- Enter below any known allergies that the child may have:
- Enter below any known medical conditions the child may have:
- Enter below any medications the child is currently taking:
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- Who provides the majority of the child care?
- Care Provider Name:
- Provider Relationship to Child:
- Provider Home/Word Telephone Number:
- Provider Cell Phone Number:
- Email Address
- Does a Second Child Care Provider exist?
- Add Alternate Care Provider:
  - Yes
  - No
- Alternate Care Provider Name:
- Alternate Provider Relationship to Child:
- Alternate Provider Home/Word Telephone Number:
- Alternate Provider Cell Phone Number:
- Email Address
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- Who should I call in case of an emergency?
- First Emergency Contact Name:
- First Emergency Contact Relationship to Child:
- First Emergency Contact Home/Work Telephone:
- First Emergency Contact Cell Phone Number:
- First Emergency Contact Email Address:
- Does a second emergency contact exist?
- Add Secondary Emergency Contact:
  - Yes
  - No
- Second Emergency Contact Name:
- Second Emergency Contact Relationship to Child:
- Second Emergency Contact Home/Work Telephone:
- Second Emergency Contact Cell Phone Number:
- Second Emergency Contact Email Address:
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- Please provide the child's health insurance details on this form.
- First Insurance Company Name:
- Policy Number:
- Group Number:
- Does the child have access to any other health insurance?
- Add another health insurance policy:
  - Yes
  - No
- Second Insurance Company Name:
- Policy Number:
- Group Number:
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- Who is the primary care physician for the child?
- Physician Name:
- Physician Address:
- City:
- State:
- Zip Code:
- Physician Telephone Number:
- Physician Email Address:
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Medical Consent PDF

Medical Form

Step 1 of 8

Who is the Parent/Guardian giving their permission/consent?

What address does the parent or guardian have?

How can you get in touch with the parent/guardian?

When will you sign this medical consent form?

For which child is this medical form being created?

Where is the address of the child?

What phone number does the child have?

For the child's medical records, kindly submit the information below.

Should this medical consent form also apply to a second child?

What is the address of this Child?

What phone number does this child have?

For this Child's medical records, kindly supply the information below.

Should this medical consent form cover a third child?

What is the address of this child?

What is the contact information for this child?

Please supply the following medical details for this child.

Should this medical consent form cover a Fourth child?

What is the address of this child?

What is the contact information for this child?

Please supply the following medical details for this child.

Who provides the majority of the child care?

Does a Second Child Care Provider exist?

Who should I call in case of an emergency?

Does a second emergency contact exist?

Please provide the child's health insurance details on this form.

Does the child have access to any other health insurance?

Who is the primary care physician for the child?