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.
(5) 5 252 528222 2588 8228222 52 522 2822 82 252885822 8582222 222882 22 522 52828522 2258228, 525 522 52828522 2258858 252885258 525 828555282 252885258.
(6) 5 58222882522 525 52522 2552 522 82828 82855525 58 5 528582 22 822552 25 8882288 552 22 52822288888822.
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
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.
(5) 5 252 528222 2588 8228222 52 522 2822 82 252885822 8582222 222882 22 522 52828522 2258228, 525 522 52828522 2258858 252885258 525 828555282 252885258.
(6) 5 58222882522 525 52522 2552 522 82828 82855525 58 5 528582 22 822552 25 8882288 552 22 52822288888822.
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
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.
