Medical Consent Form for Minor while Parents are Away Form
Minor Child Information
Child Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Parent/Guardian Name 1
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Parent/Guardian Name 2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Health Data
Does the child have any allergies?
If yes, then please specify it on the field above.
Does the child taking any prescribed medications?
If yes, then please specify it on the field above.
Does the child have any medical condition? Like Asthma, Diabetes, Cardiovascular Disease, Communicable Disease etc.
If yes, then please specify it on the field above.
Insurance Information
Health Insurance Company
Insurance Member Number
Authorization and Waiver
I authorize the assigned hospital/clinic to perform the treatment or necessary procedure for my child.
I authorize the use of anesthesia and understands the side effects my child will experience from it.
I understand the risk and complications of the procedure or treatment.
I release the assigned hospital/clinic for any responsibility in case of accident, illness, or injury.
I acknowledge that all information I provided int his form is true and accurate.
What procedures or treatment allowed in this consent?
General Medical Care
Emergency Treatment
Surgical Care
Blood Transfusion
Hospital Admission
Signature of Parent/Guardian
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: