Parental Consent Form

Date from ________________________ to ___________________________

Parental Consent of Authority to __________________________________________________

Name of Child  __________________________________________

Home Address ______________________________________________________

Telephone Number(s) _________________________________________________

Date of Birth________________

Passport No. ________________________

Doctor's name and address ____________________________________________

Doctor's Telephone ________________________

Date of last anti-tetanus injection (if known) ______________________________

bullet Has he/she been in contact with any infectious disease within the past three months? Yes No
bullet Is he/she taking any medicine that needs to be continued during the visit? Yes No
bullet Does he/she suffer from any allergies, recurrent illness or disability?  Yes No

 

Other relevant medical details:__________________________________________

Special dietary requirements:___________________________________________

I hereby give consent for the child named above to taken out of the United Kingdom. In the event of a
medical emergency I authorise the People named above to sign any consent form considered necessary by hospital authorities,
if the delay required to obtain my own consent is considered inadvisable by the doctor or surgeon concerned.

Signed ______________________________________________Parent / Guardian

Name ______________________________ Date ___________

 

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