Paediatric Consent Form
Please read and complete the following consent form for paediatric treatment.
Parent/Guardian Name
First Name
Last Name
Child's Name
First Name
Last Name
Patient No:
Date of Birth
-
Month
-
Day
Year
Date
Consent for Treatment
*
I give my consent for the healthcare provider to treat my child.
I do not give my consent for the healthcare provider to treat my child.
Allergies
Food Allergies
Medication Allergies
Environmental Allergies
Other
None
If other, please specify
If only the legal guardian or one parent is providing consent, provide reason(s) for absence of the second parent/parents
If only the mother has provided consent and the father is actively present in the child's life, has the mother contacted the father to provide verbal consent for clinical investigations, admission and/or treatment for the patient?
Yes
No
If not, then specify why
Mother
First Name
Last Name
Signature
Father
First Name
Last Name
Signature
Legal Guardian
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Medical Officer/Consultant
First Name
Last Name
Signature
Submit
Submit
Should be Empty: