Emergency treatment permission form
Pupil's name
*
First Name
Last Name
Date of Birth
*
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Day
-
Month
Year
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Home Address
*
Street Address
Street Address Line 2
Town
State / Province
Post Code
Telephone number
*
Mobile number
*
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National health number
*
Doctor's name
First Name
Last Name
Doctor's address
*
Street Address
Street Address Line 2
Town
State / Province
Post Code
Doctor's phone number
*
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Is your child allergic to anything (e.g. asprin, antibiotics, paracetamol or ibuprofen)
*
Yes
No
Details of allergies
Please list any drugs your child takes and the dosage
Date of anti-tetanus injection
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Day
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Month
Year
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Any other relevant information
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I hereby authorise Wyvern Academy to give permission to the Doctor/Nurse in charge to undertake whatever surgical, medical or dental treatment is considered necessary for my child.
*
Yes
Signature
*
Use your cursor to draw your signature in the box
Parent/Carer Name
*
First Name
Last Name
Date
*
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Day
-
Month
Year
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Submit
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