Medical Consent

Step 1 of 20

- User Email*
- Who is the parent or guardian providing consent/authorization?
- Personal Title:
- Name:
  
  First
- Address
  
  Address:
  
  City:
  
  State
- Home/Work Telephone Number:
- Cell Phone Number:
- Relationship to Child(ren):
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- On what date is this medical consent form being signed?
- Authorization Date:
  
  MM slash DD slash YYYY
- What is the name and date of birth of the child this form is being created for?
- Name:
- Date of Birth:
  
  MM slash DD slash YYYY
- What is the child's address and telephone number?
- Address
  
  Address:
  
  City
  
  State
  
  ZIP Code
- PDF Preview

- What is the child's address and telephone number?
- Telephone:
- 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:
- Do you wish to include a second child on this form?
- Include a second child?:
  - Yes
  - No
- What is the child's name?:
- What is the child's date of birth?:
  
  MM slash DD slash YYYY
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- What is the second child's address and telephone number?
- Address
  
  Street Address
  
  City
  
  State
  
  ZIP Code
- What is the second child's telephone number?
- Telephone:
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- Please provide the following medical information for the second 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:
- PDF Preview

- Do you wish to include a third child on this form?
- Include a third child?:
  - Yes
  - No
- What is the child's name?:
- What is the child's date of birth?:
  
  MM slash DD slash YYYY
- PDF Preview

- What is the third child's address and telephone number?
- Address
  
  Street Address
  
  City
  
  State
  
  ZIP Code
- What is the third child's telephone number?
- Telephone:
- PDF Preview

- Please provide the following medical information for the third 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:
- PDF Preview

- Do you wish to include a fourth child on this form?
- Include a fourth child?:
  - Yes
  - No
- Name:
- Date of Birth:
  
  MM slash DD slash YYYY
- PDF Preview

- What is the fourth child's address and telephone number?
- Address
  
  Street Address
  
  City
  
  State
  
  ZIP Code
- What is the fourth child's telephone number?
- Telephone:
- PDF Preview

- Please provide the following medical information for the fourth 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:
- PDF Preview

- What is the name and contact information of the primary child care provider?
- Care Provider Name:
- Provider Relationship to Child:
- Provider Home/Word Telephone Number:
- Provider Cell Phone Number:
- PDF Preview

- Would you like to add an alternate child care provider?
- Add alternate care provider?:
  - Yes
  - No
- PDF Preview

- What is the name and contact information of the alternate child care provider?
- Alternate Care Provider Name:
- Alternate Provider Relationship to Child:
- Alternate Provider Home/Word Telephone Number:
- Alternate Provider Cell Phone Number:
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- What is the name and contact information of the first emergency contact that you authorize to approve emergency medical/dental care for your child?
- First Emergency Contact Name:
- First Emergency Contact Relationship to Child:
- First Emergency Contact Home/Work Telephone:
- First Emergency Contact Cell Phone Number:
- Would you like to add a second emergency contact?
- Include a second emergency contact in this consent form?:
  - Yes
  - No
- PDF Preview

- What is the name and contact information of the second emergency contact that you authorize to approve emergency medical/dental care for your child?
- Second Emergency Contact Name:
- Second Emergency Contact Relationship to Child:
- Second Emergency Contact Home/Work Telephone:
- Second Emergency Contact Cell Phone Number:
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- Please provide health insurance information for the child included in this form.
- First Insurance Company Name:
- Policy Number:
- Group Number:
- Is the child covered under another health insurance policy?
- Add another health insurance policy?:
  - Yes
  - No
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- What is the child's second health insurance information?
- Second Insurance Company Name:
- Policy Number:
- Groupt Number:
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- What is the name and contact information of the child's primary care physician?
- Physician Name:
- Address
  
  Physician Address:
  
  City
  
  State
  
  ZIP Code
- Physician Telephone Number:
- PDF Preview

PDF Preview

MEDICAL & DENTAL RELEASE FORM
FOR MINOR

I, ${input_55_2} . ${input_55_3_3} , certify that I am the parent or legal guardian of the minor listed below, and as such, I hereby convey temporary authority to the below designated adults for the sole purpose of obtaining or arranging any emergency medical or dental care for the minor as may be deemed necessary for the well-being of my when not accompanied by a parent/legal guardian or should either parent/legal guardian be unreachable by telephone.

THEREFORE, I hereby approve and empower the below listed individuals with the authority to arrange and/or consent for any and all emergency medical/dental care and treatment of my in my absence.

_____________________________ (Signature of Parent/Legal Guardian)	${input_55_10} _____________________________ (Date)
${input_55_3_3} _____________________________ (Name of Parent/Legal Guardian)	${input_55_7} _____________________________ (Relationship to )
${input_55_121} _____________________________ (Home/Work Number)	${input_55_122} _____________________________ (Cell Number)

MINOR

Child’s Name: ${input_55_13_3} :

Address: ${input_55_17_1} , ${input_55_17_3} , ${input_55_17_4} ${input_55_17_5}

Telephone Number: ${input_55_123} :

Date of Birth: ${input_55_14} :

Parent/Legal Guardian: ${input_55_3_3}

Address: ${input_55_4_1} , ${input_55_4_3} , ${input_55_4_4}

Home/Work Telephone: ${input_55_121}

Cell Telephone: ${input_55_122}

Allergies:

Medical Conditions:

Current Medications:

PRIMARY CHILD CARE PROVIDER

${input_55_75} _____________________________ (Primary Child Care Provider Name)	${input_55_76} _____________________________ (Relationship to Minor Child)
${input_55_77} _____________________________ (Home/Work Telephone Number)	${input_55_78} _____________________________ (Cell Phone Number)

AUTHORIZED EMERGENCY CONTACTS

${input_55_90} _____________________________ (Emergency Contact Name)	${input_55_91} _____________________________ (Relationship to Minor Child)
${input_55_92} _____________________________ (Home/Work Telephone Number)	${input_55_93} _____________________________ (Cell Phone Number)

HEALTH INSURANCE & DOCTOR INFORMATION

Insurance Company: ${input_55_105}

Policy Number: ${input_55_106}

Group Number: ${input_55_107}

Physician’s Name: ${input_55_118}

Address: ${input_55_119_1} , ${input_55_119_3} , ${input_55_119_4} ${input_55_119_5}

Telephone Number: ${input_55_120}

Medical Consent

Step 1 of 20

Who is the parent or guardian providing consent/authorization?

On what date is this medical consent form being signed?

What is the name and date of birth of the child this form is being created for?

What is the child's address and telephone number?

What is the child's address and telephone number?

Do you wish to include a second child on this form?

What is the second child's address and telephone number?

What is the second child's telephone number?

Please provide the following medical information for the second child.

Do you wish to include a third child on this form?

What is the third child's address and telephone number?

What is the third child's telephone number?

Please provide the following medical information for the third child.

Do you wish to include a fourth child on this form?

What is the fourth child's address and telephone number?

What is the fourth child's telephone number?

Please provide the following medical information for the fourth child.

What is the name and contact information of the primary child care provider?

Would you like to add an alternate child care provider?

What is the name and contact information of the alternate child care provider?

What is the name and contact information of the first emergency contact that you authorize to approve emergency medical/dental care for your child?

Would you like to add a second emergency contact?

What is the name and contact information of the second emergency contact that you authorize to approve emergency medical/dental care for your child?

Please provide health insurance information for the child included in this form.

Is the child covered under another health insurance policy?

What is the child's second health insurance information?

What is the name and contact information of the child's primary care physician?