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Medical Consent PDF
Medical Consent
Medical Form
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Who is the Parent/Guardian giving their permission/consent?
Personal Title:
Mr.
Mrs.
Ms.
Miss.
Name:
Relationship to Child(ren):
Parent/Legal Guardian Signature
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Max. file size: 2 MB, Max. files: 1.
What address does the parent or guardian have?
Address
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
PDF Preview
Who is the primary care physician for the child?
Physician Name:
Physician Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Physician Telephone Number:
Physician Email Address:
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