CHILD HEALTHCARE CONSENT FORM
This Child Healthcare Consent Form is signed on ________ at Andaman and Nicobar Islands.
I ________ with permanent address at: ________, do hereby declare that I am the Parent of the following Child: ________, gender of the Child: Male, aged: ________ years, born on: ________, at the following place: ________.
I do grant ________ ("Caregiver") with the following correspondence address: ________, the authority to obtain medical treatment to the aforementioned Child. The Caregiver have the following relationship with the Child: ________.
I specifically grant permission to the aforementioned Caregiver to do the following in relation to providing health care services:
a. Do routine medical care and treatment.
b. Administer medications to the Child as prescribed and required.
c. Provide over the counter medications as prudent and necessary.
d. Emergency medical care and treatment.
e. Hospitalization.
f. Consent to the surgery.
g. Dental care and treatment.
h. Provide permission to anesthesia and surgical procedures.
552 855228825 252 5582 588288 22 522 525 588 5282558, 828855822, 852 222 8828225 22 828555282 5282558 522555822 522 2258858 82588828 25 252522222 25288525.
The purpose of this consent form is to give ________ the authority to provide and consent to the medical treatment of My Child. This authority will be effective from ________ and continue till ________.
Health Condition of Child
My Child has the following special conditions/allergies:
________
My Child is taking the following medications:
________
The details of the last Tetanus injection/Booster shot was taken on:
________
In case of normal check-up and consultation, the Caregiver may prefer the following physician:
________
The following are the insurance details of the Child:
Name of insurance company: ________
Policy No: ________
Name of policy holder: ________
Contact details of Parent:
In case of emergency, the Parent can be contacted at the following contact details:
Name: ________ (Parent)
Address: ________
Phone no: ________
Email: ________
Emergency Contact Details
In case of emergency, if the Parent is not available the Caregiver or concerned person can contact the following emergency contact:
Name: ________
Phone: ________
Email: ________
_______________
Signature
________
(Parent)
CHILD HEALTHCARE CONSENT FORM
This Child Healthcare Consent Form is signed on ________ at Andaman and Nicobar Islands.
I ________ with permanent address at: ________, do hereby declare that I am the Parent of the following Child: ________, gender of the Child: Male, aged: ________ years, born on: ________, at the following place: ________.
I do grant ________ ("Caregiver") with the following correspondence address: ________, the authority to obtain medical treatment to the aforementioned Child. The Caregiver have the following relationship with the Child: ________.
I specifically grant permission to the aforementioned Caregiver to do the following in relation to providing health care services:
a. Do routine medical care and treatment.
b. Administer medications to the Child as prescribed and required.
c. Provide over the counter medications as prudent and necessary.
d. Emergency medical care and treatment.
e. Hospitalization.
f. Consent to the surgery.
g. Dental care and treatment.
h. Provide permission to anesthesia and surgical procedures.
552 855228825 252 5582 588288 22 522 525 588 5282558, 828855822, 852 222 8828225 22 828555282 5282558 522555822 522 2258858 82588828 25 252522222 25288525.
The purpose of this consent form is to give ________ the authority to provide and consent to the medical treatment of My Child. This authority will be effective from ________ and continue till ________.
Health Condition of Child
My Child has the following special conditions/allergies:
________
My Child is taking the following medications:
________
The details of the last Tetanus injection/Booster shot was taken on:
________
In case of normal check-up and consultation, the Caregiver may prefer the following physician:
________
The following are the insurance details of the Child:
Name of insurance company: ________
Policy No: ________
Name of policy holder: ________
Contact details of Parent:
In case of emergency, the Parent can be contacted at the following contact details:
Name: ________ (Parent)
Address: ________
Phone no: ________
Email: ________
Emergency Contact Details
In case of emergency, if the Parent is not available the Caregiver or concerned person can contact the following emergency contact:
Name: ________
Phone: ________
Email: ________
_______________
Signature
________
(Parent)
Answer the question, then click on "Next".
The document is written according to your responses - clauses are added or removed, paragraphs are customised, words are changed, etc.
At the end, you will immediately receive the document in Word and PDF formats. You can then open the Word document to modify it and reuse it however you wish.
