Parent or guardian consent for a child form

About the child

1. Child's full name Short answer · required
2. Child's date of birth Date · required
3. School or sport (optional) Short answer

Parent or guardian

1. Your full name Short answer · required
2. Relationship to the child Choose one: Parent · Legal guardian · Other (please explain below) · required
3. Your phone number Short answer · required
4. Other adults who may bring the child to appointments Written answer
5. Consent for a child To read and agree to · required I consent to my child being assessed and treated by physiotherapy. I understand a parent or guardian is welcome in the room, and that I may stop treatment at any time.
6. I am the parent or legal guardian and I consent Tick box · required

Signature

1. Your full name Short answer · required
2. Date Date · required

Signature

The patient signs on screen, on their phone or at the front desk, and the signed copy is kept on their file.