Passport sized photograph of
child
MEDICAL FORM
Child’s Name: Child’s Date of Birth: Gender: Boy Girl Name of Doctor (Clinic): Clinic / Mobile No.:
Y N Type of Illness Y N
Measles Diabetes Type 1 or 2 German Measles Epilepsy Chicken Pox Heart Trouble Mumps Rheumatic Fever Whooping Cough Asthma Scarlet Fever Convulsions Hand, Foot & Mouth Disease
Kidney Disease Infectious Hepatitis Tuberculosis Poliomyelitis Hearing Difficulty Pneumonia Vision Difficulty Malaria Speech Difficulty Meningitis Rheumatism Chronic illness Skin Disorder / Eczema Bronchitis Convulsions
Child’s Pediatrician Details:
Child’s Health History (Please indicate if your child has had any of thefollowing conditions / illnesses)Type of Illness
Do you Need to supply the nursery with Medication for your child? If yes, please give detailsof the medications and the reasons for this:
Administration of ‘over the counter’ medicine
Emergency Treatment
Name : …………………….............…
Signature : ………………………………… Date : …………………………..
In the Event of an emergency, I here by authorize the SBN staff to take my child to a doctor or to the hospital for treatment or call an ambulance, and any expense of this service will be acceppted by me.
I give my permission to the nursery to administer Adol/Calpol Syrup (pain/fever reliever), If my child develops a fever, or has pain, or a mild allergic reaction.
MEDICAL CONSENT
For Display on Classroom & Nurse’s Information Board
Full name of Child (Write in BLOCK CAPITAL LETTERS)
I am Allergic to: ______________________________________________________________
Reactions include: ____________________________________________________________
Please use my (Supplied) Medication
Name of (Supplied) Medication and how to administer:
Emergency contact number in case of an emergency: ________________________________
ALLERGY ALERT!!
P.O. Box : 67022, API Residency,Opp. NMC Hospital, Al Nahada 1, Dubai - UAE.
Phone : 04 266 3299 / 04 2666 [email protected] | www.singingbirdsnursery.com