Medical Release Form Parents
A medical release form parents enables a care-giver to seek medical attention for your child in your absence. There are many non- life threatening ailments which doctors and medical practitioners will not treat without documented parental consent as they risk facing a lawsuit.
Sample Medical Release Form Parents
Child’s name: _________________________ Date of birth: __________________
Name of Pediatrician: ___________________ Tel no: _______________________
Father’s name: _________________________ Tel no: _______________________
Mother’s name: ________________________ Tel no: _______________________
Please fill out the following information concerning your child.
Allergies recurring illness Medication Surgery
_______________ _____________________ _______________ ____________
_______________ _____________________ _______________ ____________
I __________________________ (name of parent (s)) do hereby give my consent to
_______________________ (name of care- giver) to seek medical attention for non- life
threatening ailments for my child ____________________ (name of child) in the event
that I am not present.
Parent’s sig: _____________________________ Date: _________________________
Name of notary: __________________________ Sig: __________________________
Category: Medical Forms
