Child Care Provider Medical Consent Form
Valid from (date) to (date)
Child 1 Information
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Child’s Name:__________________________
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Child’s Date of Birth:_____________
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Child’s Doctor:__________________________
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Doctor’s Phone Number:__________
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Preferred Hospital: ______________________
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Child’s Allergies and Medical Conditions: _____________________________________
Child’s Past Surgeries:____________________________________________________
Child’s Medications:______________________________________________________
Child’s Health Insurance Provider:______________
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Policy Number:_______________
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Child 2 Information
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Child’s Name:__________________________
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Child’s Date of Birth:_____________
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Child’s Doctor:__________________________
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Doctor’s Phone Number:__________
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Preferred Hospital: ______________________
Child’s Allergies and Medical Conditions: _____________________________________
Child’s Past Surgeries:____________________________________________________
Child’s Medications:______________________________________________________
Child’s Health Insurance Provider:______________
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Policy Number:_______________
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Child 3 Information
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Child’s Name:__________________________
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Child’s Date of Birth:_____________
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Child’s Doctor:__________________________
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Doctor’s Phone Number:__________
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Preferred Hospital: ______________________
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Child’s Allergies and Medical Conditions: _____________________________________
Child’s Past Surgeries:____________________________________________________
Child’s Medications:______________________________________________________
Child’s Health Insurance Provider:_________ Policy Number:______ Policy Number:_______
Parent/Guardian Information
Custodial Parent/Guardian Name(s):__________________ Phone Number:________________
Address:______________________________________________________________________
Custodial Parent/Guardian Name(s):__________________ Phone Number:________________
Address:______________________________________________________________________
Caregiver Information
In the case that no parent/guardian can be reached, please allow the following named individual to make medical decisions for the above named child/children:
Caregiver’s Full Legal Name:______________________________ Date of Birth:____________
Address:______________________________________________ Phone Number:__________
Relationship to Child:________________________