Medical Permission Form
A medical permission form protects doctors and practitioners from being sued for treating a child who is a minor without parental permission. In the event that your child needs medical attention for an ailment that is not life threatening then a medical permission form which indicates parental consent must be presented.
Sample Medical Permission Form
Name of child: _______________________ Age: _________________________
Name of mother: _____________________ Tel no: _______________________
Name of father: ______________________ Tel no: _______________________
Please fill out the following information:
I ___________________________ (name of parent) on this day _______________ of
_____________ Year _______________ do hereby grant permission for my child
_________________________ (name of child) to receive medical treatment in the event
that I am not present or available. I give permission to ______________________ (name
of teacher, babysitter etc) to seek medical attention for my child on my behalf.
Mother’s sig: _________________________ Date: _________________________
Father’s sig: __________________________ Date: _________________________
Name of notary: _______________________ Sig: __________________________
Category: Medical Forms
