Medical Permission Slip Template - PDF Templates

Medical Permission Slip

Parental Information

Name of Father

James Brennan

Phone Number of Father

(111) 111-1111

Email Address of Father

example@example.com

Name of Mother

Penny Web

Phone Number of Mother

(111) 111-1111

Email Address of Mother

example@example.com

Child's Information

Name of Child

Maurice Buchholtz

Date of Birth

Thursday, January 8, 2015

Child's Medical Information

Blood Type

A+

Food Allergies

Eggs

Drug Allergies

None

Name of Pediatrician

Mildred H. Smith

Phone Number of Pediatrician

(333) 333-3333

Policy Number

12345678

Medical Permission C

onsent

In case of emergency and I am unable to be reached, I authorize medical treatment to be given to my child by a licensed medical professional. This authorization includes any necessary tests, procedures, or medications that the medical professional deems necessary for the treatment of my child's medical condition.
I understand that the medical professional will make every effort to contact me or the emergency contact listed above prior to administering any medical treatment to my child, unless it is determined that immediate treatment is required.
I certify that my child is not allergic to any medications and does not have any medical conditions that would prevent him/her from receiving medical treatment.
I understand that this consent form will remain in effect until revoked by me in writing.

Date

03/16/2023

Signature of Father