To create a medical permission slip, decide on the parameters, title the form, include the full name and relationship to the child, the chosen medical parameters, relevant contact information and the start and end date of the authorization. Distribute the slip appropriately.Continue Reading
Decide on who is covered by the consent form. This is usually child care providers or school nurses. Decide also on the level of treatment, such as emergency medical care or chronic illness treatment, that is authorized.
Type in bold and all capitals the title "Medical Authorization Form." Make the title a larger font than the rest of the document.
In the body of the form, start with the sentence "We, the undersigned," and put your full name. Next, state your relationship to the children followed by their full names. Include their birthdays.
Write the full name of the caretakers involved and their relationships to the children.
Dictate how much medical treatment the caretakers may authorize. Be specific, and include when the authorization stops and ends.
If you want to be contacted right away, include this in the letter. State your place of work as well as the phone number. If there is another emergency contact, include the name, relationship and phone number of this person.
Include insurance information, the child's primary physician and any medical allergies. If you have a preferred hospital, include that information.
Sign the form above a typed line of your name, and include the date.
Give a copy of the form to the relevant caretaker, your pediatrician, your insurance company and your child's school.