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CHILD MEDICAL CONSENT ("Consent")
I, ________, of ________, declare that I am the parent/legal guardian of the following child ("Child"):
CHILD'S INFORMATION
Personal details
Name: ________
Gender: Male
Date of birth: ________
Medicare information
Medicare card number: ________
Expiry date: ________
Insurance information
Health insurance provider: ________
Membership number: ________
Details of treating doctor
Doctor name: ________
Medical centre: ________
Phone: ________
Email: ________
Special medical needs, conditions, illnesses or allergies
________
Current medication
________
Vaccination details
________
AUTHORISATION
(1) I hereby consent to the following medical treatment for my Child:
________
(2) I authorise the ________ of ________ to communicate with any persons who are providing assistance to my Child in accordance with this Consent and, if necessary in the best interests of my Child, to provide information to those persons regarding my Child's medical history, medical conditions, and medical treatments.
(3) I confirm that the any person who acts under this Consent must at all times act in the best interests of the Child.
(4) I give this Consent voluntarily and not as a result of any payment, coercion or duress. I consider that it is in the best interests of the Child for me to provide this Consent.
CONTACT DETAILS
(1) If the Child is sick or injured, any relevant persons must first attempt to contact me using the following details:
Name: ________
Address: ________
Phone: ________
Email: ________
(2) If I cannot be reached, the following emergency contact person may be contacted instead:
Name: ________
Address: ________
Phone: ________
Email: ________
EXECUTED THIS ________ at ________.
Signed by the Parent:
_______________________________________
________
Before the following witness:
_______________________________________
Witness signature
_______________________________________
Witness name
_______________________________________
Witness title
_______________________________________
_______________________________________
Witness address
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