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Parental Consent Form

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Varun Malik
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7 views2 pages

Parental Consent Form

Uploaded by

Varun Malik
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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UTTAM PRAKASH AGARWAL COLLEGE OF COMMERCE AND

ECONOMICS,
MANAGED BY SHANTABEN B. CHAUHAN EDUCATION TRUST
(Affiliated to Mohanlal Sukhadiya University) (Accredited by Department Of
College Education, Govt. Of Rajasthan)

PARENTAL CONSENT FORM FOR SURGERY

I………………………………………..… am the parent/guardian of …………………………..,


who is a student at Upaca Gurukul ,Abu Road (“The Institute”)

I understand that ………………………… requires medical treatment/medication/surgery as


deemed necessary by medical professionals at……………………………………………
(Hospital Name). Unfortunately, due to unforeseen circumstances, I am unable to be present
during the medical treatment/medication/surgery.

I hereby authorize the medical staff at …………………………………………………(Hospital)


to perform the necessary medical treatment/medication/surgery and any related procedures as
recommended by the medical professionals involved in
……………………………………………..(Students name) care.

Details of medical treatment/medication/surgery:

Type of medical treatment/medication/surgery:


Date and Time:
Location:
Emergency Contact Information:

In case of any emergency or unforeseen circumstances, the following individual is authorized to


make decisions on my behalf:

Emergency Contact Name:


Relationship to Student:
Contact Number:
Alternate Contact Number:

Shantaben B. Chauhan Education Trust


Smt. Radhadevi Jagdishprasad Agarwal Knowledge Center,IP 4-5, RIICO Growth Center,
Phase-II, Mawal Abu Raod 307026
UTTAM PRAKASH AGARWAL COLLEGE OF COMMERCE AND
ECONOMICS,
MANAGED BY SHANTABEN B. CHAUHAN EDUCATION TRUST
(Affiliated to Mohanlal Sukhadiya University) (Accredited by Department Of
College Education, Govt. Of Rajasthan)

I HEREBY AFFIRM:

1. That I understand the risks and benefits associated with the proposed medical
treatment/medication/surgery, and I trust the medical professionals to make decisions in
the best interest of my child.
2. That I understand that the medical professionals and The Institute are acting in the best
interest of my child and that this medical treatment/medication/surgery and matters
incidental are for the benefit of my child.
3. That I understand and agree that The Institute shall bear no liability borne out of this
surgery as they are just providing assistance for connecting students with hospitals and
medical professionals for the aforesaid medical treatment/medication/surgery.

This Parental Consent Form is valid for the duration of the medical treatment/medication/surgery
and any immediate post-operative or follow-up care necessary.

Parent/Guardian Information:

Parent/Guardian Full Name:


Relationship to Student:
Address:
Email Address:
Contact Number:
Date and Signature:

Date:
Parent/Guardian Signature:

Shantaben B. Chauhan Education Trust


Smt. Radhadevi Jagdishprasad Agarwal Knowledge Center,IP 4-5, RIICO Growth Center,
Phase-II, Mawal Abu Raod 307026

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