Parent/legal guardian consent form

Parent/legal guardian consent form

for paediatric physiotherapy
Child's Name*

First NameLast Name
Child's Date of Birth*

DayMonthYear
Post Code

Street Address

Street Address Line 2

CityCounty

Post Code
* Please enter either a landline or mobile number below. This is required if we need to contact you about the information you provide on this form. Your private data will not be shared with any third party.
Parent / Legal guardian Name*
Full name
Your Mobile Number*
Mobile phone number
Your Landline Number (unnecessary if mobile number provided)

Area CodePhone Number
Email*
example@example.com
For Parent/Guardian use only. Please tick ALL relevant boxes below.*

I confirm that I am the legal guardian/parent of the above named patient.The patient will be above13 and below 16 years of age at the time of the appointment.I hereby consent for the above named patient to attend for future physiotherapy appointment unaccompanied by a legal guardian/parent.I confirm that this has been discussed and agreed with the treating physiotherapist.The patient is above 16 and below 18 years of age and it has been decided they will attend future appointments independently
The name of the treating physiotherapist is – *
Once we receive the completed form, the treating clinician will be informed, and a copy of the form will kept in the patient's notes.
Signature*

I am the patient's parent/legal guardian
To draw your signature: Place the mouse cursor in the area below, click and hold the left mouse button then move the mouse as if you were drawing.*
Should be Empty: