Medical Consent Form

Medical Consent Form
Please have these forms completed by a physician. You can do so by printing the form out and having your physician complete it manually, or by typing in the results of the recent physical report your physician has carried out on your child. "Print Form" button is available at the end of this form. Please provide the information in English or in Medical Terminology.

Personal Information
Student Name*
First NameLast Name
Parent Name*
First NameLast Name
Phone Number*
Area CodePhone Number
Contact E-mail*

Medical History
Please provide necessary medical history information that has, does, or could affect your child.
AllergiesFrequent Sore ThroatChronic TonsilitisSinusitisOtitis MediaHepatitisConvulsions/EpilepsyMenstrual CycleUrinary InfectionsHeart DisordersRheumatic FeverDiabetesBronchitisAsthmaDrug ReactionsFrequent CoughFrequent RhinitisFrequent InfluenzaInjuriesPains
TuberculosisGerman MeaslesMumpsChickenpoxPolioWhooping coughMeaslesScarlet FeverDiphtheria
Daily medicationSpecial dietDiarrhea or constipationChronic medical conditionHad operationsHas been treated in a hospital
Has seen (or is currently seeing) a counselor, psychologist or psychiatristHas received (or is currently receiving) academic support servicesHas received (or is currently receiving) special individual educational assessments
Please provide more detailed information

Physical Examination
Height
cm
Weight
kg
Blood
pressure
Skin
condition
Throat
condition
Teeth
condition
Ears
condition
Lungs
condition
Vision
condition
Heart
condition
Abdomen
condition
Hernia
condition
Urine
condition
Indigestion
condition
General Condition

Medical Permission
I hereby give my permission to the school for my child to:
Receive dental treatment and services if required.Receive orthodontic treatments.Receive an eye examination or re-examination.Order glasses or contact lenses if needed.Consent for flu vaccination.
I hereby give permission for emergency medical and surgical treatments of my child as may be considered necessary by the attending physician(s).
Parent / Guardian*
I hereby attest that all information listed on all medical forms is true.
Should be Empty: