Medical Consent Form

I hereby give The Rim permission to admiinster listed medications to my child below:

Yes

No

Child Name:

First

Last

Parent or Guardian Name:

First

Last

Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry

E-mail:

Phone:

Area Code

-

Phone Number

Insurance Provider:

Pediatrician & preferred Hospital:

All Allergies:

Medicine currently taking & times:

Date: