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 196info@singingbirdsnursery.com | www.singingbirdsnursery.com