Child Healthcare Consent Form - Template, Sample Form

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.

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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

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Name: ________

Phone: ________

Email: ________

_______________

Signature

________

(Parent)