Create Child Medical Consent "*" indicates required fields Step 1 of 3 - Parent Information 33% HiddenUser Logged In? Contact InformationYour Name* First Last Email*Your completed document will be sent instantly to the following email address. Already have an account?Login now.Parent of Legal Guardian InformationParent of Legal Guardian Name* First Last Guardian's Relationship to Child* Parent Legal Guardian Parent of Legal Guardian Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneTemporary Caregiver InformationCaregiver's Name* Caregiver's Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Caregiver's Relationship to Child* An educational institution in which the child is enrolled. An adult who has the care and control of the child. Other Other Child's InformationChild's Name* First Last Child's Gender*MaleFemaleChild's Date of Birth* MM slash DD slash YYYY Include child's health information?* Yes No Current Health Condition(s)Allergies to Medication and FoodPrescriptionsDate of Last Tetanus Injection/Booster MM slash DD slash YYYY Include child's primary physician?* Yes No Physician's Name* First Last Physician's Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician's Phone*Include child's insurance information?* Yes No Insurance Provider* Policy Holder's Name* First Last Policy Holder's Date of Birth* MM slash DD slash YYYY Policy Number / Member ID* Include authorized treatments?* Yes No Authorized Treatments* Routine medical care and treatment Emergency medical care and treatment Dental care and treatment Other Other Treatments PDF Preview Full Screen Rotate your phone sideways for larger preview. Almost there! Complete secure checkout on the next page to receive your PDF without any watermarks or restrictions. Click "Previous" if you still have some edits to make.PhoneThis field is for validation purposes and should be left unchanged. 100% Private & Secure Over 11K + Happy Customers
