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Library

Online Medical Consent Form/Consentimiento Médico

- Faith Formation

Medical Consent Form/ Consentimiento Médico
The maximum number of form submissions has been reached. This form is currently not available.
- Will be kept on file for childcare needs, but must be resubmitted on an annual basis.
  Se mantendrá en archivo para las necesidades de cuidado de los niños, pero se tiene que volver a presentar
  sobre una base anual.
- Medical Matters/Asuntos Médicos
  I hereby warrant to the best of my knowledge, my child/children are in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes.
  Certifico por este medio que al mejor de mi conocimiento, mi hijo(a), está en buena salud y asumo toda la responsabilidad por la salud de mi hijo(a). En las declaraciones siguientes, firme solamente aquéllas con las que esté de acuerdo.
- Emergency Medical Treatment/Tratamiento Médico de Emergencia
  
  Parent's/Guardian's Name/Nombre del padre / tutor REQUIRED Please fill out this field. Please enter valid data.
  
  In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment.
  En caso de una emergencia, doy permiso de transportar a mi hijo(a) a un hospital para tratamiento médico o quirúrgico de emergencia.
  
  Transport to Hospital/Transporte al hospital REQUIRED Please fill out this field.
  
  I wish to be advised prior to any further treatment by the hospital or doctor.
  Pido ser notificado antes de que el hospital o los médicos hagan cualquier tratamiento adicional.
  
  Advisement prior to any further treatment/Asesoramiento antes de cualquier tratamiento adicional REQUIRED Please fill out this field.
  
  In the event of an emergency and you are unable to reach me, contact:/ En el caso de una emergencia y usted no puede llegar a mí, comuníquese con:
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship/Relación REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor
  
  Doctor's Name/El Nombre del Doctor Please enter valid data.
  
  Phone Number Please enter a phone number.
- Children's Medical Information/Información Médica de (los) Niño(s) REQUIRED Please fill out this field.
  
  Child/Niño 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth/Fecha de Nacimiento REQUIRED Please fill out this field. Please enter valid data.
  
  The only medications that will be administered in childcare will be asthma & life saving allergy medications. All medications must come in the original packaging and include doctor's prescription label with child's name, dosage and frequency.
  Los únicos medicamentos que se administrarán en el cuidado de los niños serán medicamentos para alergias y para el asma. Todos los medicamentos tienen que venir en el embalaje original e incluir la etiqueta de prescripción del médico con el nombre del niño, la dosis y la frecuencia.
  
  Medication(s)/Medicamento(s)
  
  Medical Conditions Information/Información sobre Condiciones Médicas
  Childcare personnel will take reasonable care to see that the following information will be held in confidence./El personal de Cuidado de Niños, tomará el cuidado de mantener esta información confidencial.
  
  My son/daughter has [Mi hijo(a) tiene]: Please enter valid data.
  
  Has had an episode the following or has been diagnosed: REQUIRED
  Un episodio de o se le ha diagnosticado:
  Please fill out this field.
  
  Allergic reactions to the following (foods, dyes, latex etc.)
  Reacciones alérgicas a: (alimentos, tintes, látex, etc.)
  
  Has had a medical surgery within the last six months? REQUIRED
  Ha sido sometido a cirugía médica dentro de los últimos seis meses?
  Please fill out this field.
  
  Is under doctor's care? REQUIRED
  Está bajo cuidado médico?
  Please fill out this field.
  
  Has a medically prescribed diet? REQUIRED
  Tiene una dieta prescrita por su médico?
  Please fill out this field.
  
  Has the following physical limitations?
  Tiene las siguientes limitaciones físicas
  
  Immunizations current and up to date (including tetanus/diphtheria) REQUIRED
  Sus inmunizaciones/vacunas están actualizadas (incluso Tétanos / difteria) :
  Please fill out this field.
  
  You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
  Ustedes deben estar enterados de las siguientes condiciones médicas de mi hijo(a):
  
  Child/Niño 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth/Fecha de Nacimiento REQUIRED Please fill out this field. Please enter valid data.
  
  The only medications that will be administered in childcare will be asthma & life saving allergy medications. All medications must come in the original packaging and include doctor's prescription label with child's name, dosage and frequency.
  Los únicos medicamentos que se administrarán en el cuidado de los niños serán medicamentos para alergias y para el asma. Todos los medicamentos tienen que venir en el embalaje original e incluir la etiqueta de prescripción del médico con el nombre del niño, la dosis y la frecuencia.
  
  Medication(s)/Medicamento(s)
  
  Medical Conditions Information/Información sobre Condiciones Médicas
  Childcare personnel will take reasonable care to see that the following information will be held in confidence./El personal de Cuidado de Niños, tomará el cuidado de mantener esta información confidencial.
  
  My son/daughter has [Mi hijo(a) tiene]: Please enter valid data.
  
  Has had an episode the following or has been diagnosed: REQUIRED
  Un episodio de o se le ha diagnosticado:
  Please fill out this field.
  
  Allergic reactions to the following (foods, dyes, latex etc.)
  Reacciones alérgicas a: (alimentos, tintes, látex, etc.)
  
  Has had a medical surgery within the last six months? REQUIRED
  Ha sido sometido a cirugía médica dentro de los últimos seis meses?
  Please fill out this field.
  
  Is under doctor's care? REQUIRED
  Está bajo cuidado médico?
  Please fill out this field.
  
  Has a medically prescribed diet? REQUIRED
  Tiene una dieta prescrita por su médico?
  Please fill out this field.
  
  Has the following physical limitations?
  Tiene las siguientes limitaciones físicas
  
  Immunizations current and up to date (including tetanus/diphtheria) REQUIRED
  Sus inmunizaciones/vacunas están actualizadas (incluso Tétanos / difteria) :
  Please fill out this field.
  
  You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
  Ustedes deben estar enterados de las siguientes condiciones médicas de mi hijo(a):
  
  Child/Niño 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth/Fecha de Nacimiento REQUIRED Please fill out this field. Please enter valid data.
  
  The only medications that will be administered in childcare will be asthma & life saving allergy medications. All medications must come in the original packaging and include doctor's prescription label with child's name, dosage and frequency.
  Los únicos medicamentos que se administrarán en el cuidado de los niños serán medicamentos para alergias y para el asma. Todos los medicamentos tienen que venir en el embalaje original e incluir la etiqueta de prescripción del médico con el nombre del niño, la dosis y la frecuencia.
  
  Medication(s)/Medicamento(s)
  
  Medical Conditions Information/Información sobre Condiciones Médicas
  Childcare personnel will take reasonable care to see that the following information will be held in confidence./El personal de Cuidado de Niños, tomará el cuidado de mantener esta información confidencial.
  
  My son/daughter has [Mi hijo(a) tiene]: Please enter valid data.
  
  Has had an episode the following or has been diagnosed: REQUIRED
  Un episodio de o se le ha diagnosticado:
  Please fill out this field.
  
  Allergic reactions to the following (foods, dyes, latex etc.)
  Reacciones alérgicas a: (alimentos, tintes, látex, etc.)
  
  Has had a medical surgery within the last six months? REQUIRED
  Ha sido sometido a cirugía médica dentro de los últimos seis meses?
  Please fill out this field.
  
  Is under doctor's care? REQUIRED
  Está bajo cuidado médico?
  Please fill out this field.
  
  Has a medically prescribed diet? REQUIRED
  Tiene una dieta prescrita por su médico?
  Please fill out this field.
  
  Has the following physical limitations?
  Tiene las siguientes limitaciones físicas
  
  Immunizations current and up to date (including tetanus/diphtheria) REQUIRED
  Sus inmunizaciones/vacunas están actualizadas (incluso Tétanos / difteria) :
  Please fill out this field.
  
  You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
  Ustedes deben estar enterados de las siguientes condiciones médicas de mi hijo(a):
  
  Child/Niño 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth/Fecha de Nacimiento REQUIRED Please fill out this field. Please enter valid data.
  
  The only medications that will be administered in childcare will be asthma & life saving allergy medications. All medications must come in the original packaging and include doctor's prescription label with child's name, dosage and frequency.
  Los únicos medicamentos que se administrarán en el cuidado de los niños serán medicamentos para alergias y para el asma. Todos los medicamentos tienen que venir en el embalaje original e incluir la etiqueta de prescripción del médico con el nombre del niño, la dosis y la frecuencia.
  
  Medication(s)/Medicamento(s)
  
  Medical Conditions Information/Información sobre Condiciones Médicas
  Childcare personnel will take reasonable care to see that the following information will be held in confidence./El personal de Cuidado de Niños, tomará el cuidado de mantener esta información confidencial.
  
  My son/daughter has [Mi hijo(a) tiene]: Please enter valid data.
  
  Has had an episode the following or has been diagnosed: REQUIRED
  Un episodio de o se le ha diagnosticado:
  Please fill out this field.
  
  Allergic reactions to the following (foods, dyes, latex etc.)
  Reacciones alérgicas a: (alimentos, tintes, látex, etc.)
  
  Has had a medical surgery within the last six months? REQUIRED
  Ha sido sometido a cirugía médica dentro de los últimos seis meses?
  Please fill out this field.
  
  Is under doctor's care? REQUIRED
  Está bajo cuidado médico?
  Please fill out this field.
  
  Has a medically prescribed diet? REQUIRED
  Tiene una dieta prescrita por su médico?
  Please fill out this field.
  
  Has the following physical limitations?
  Tiene las siguientes limitaciones físicas
  
  Immunizations current and up to date (including tetanus/diphtheria) REQUIRED
  Sus inmunizaciones/vacunas están actualizadas (incluso Tétanos / difteria) :
  Please fill out this field.
  
  You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
  Ustedes deben estar enterados de las siguientes condiciones médicas de mi hijo(a):
- Insurance Information/Información sobre Seguro Médico
  
  Insurance/Seguro I have insurance/Tengo seguro I do not have insurance/No tengo seguro
  
  Insurance Carrier/Portador del seguro: Please enter valid data.
  
  Name of insured/Nombre del asegurado: Please enter valid data.
  
  Insurance Policy Number/Número de Póliza de Seguro Please enter valid data.
  
  Father's Name/Nombre del Padre Please enter valid data.
  
  Father's Phone Number/Número de teléfono del padre Please enter a phone number.
  
  Mother's Name/Nombre de la Madre Please enter valid data.
  
  Mother's Phone Number/Número de teléfono de la madre Please enter a phone number.
- Parents will be contacted immediately if child becomes ill with symptoms such as headache, vomiting, sore throat, fever, or diarrhea.
  Los padres serán contactados inmediatamente si el niño se enferma con síntomas como dolor de cabeza, vómito, dolor de garganta, fiebre o diarrea.
  I Understand/Entiendo Please select this field.
- I am the parent or legal guardian/ Soy el padre o guardián legal
  I Agree/Estoy de Acuerdo Please select this field.
- Date/Fecha REQUIRED Please fill out this field. Please enter a date.
- Please leave cell phone on vibrate while attending meeting or event.
  Deje por favor el teléfono celular en vibrar mientras que asiste a la reunión o evento.
Submit

The Catholic Community of

St. Luke the Evangelist

Online Medical Consent Form/Consentimiento Médico

Medical Consent Form/ Consentimiento Médico