Pediatric Consent Form

A pediatric range ranges from the time of birth to the age of 13 years, after which adulthood starts. In medicine, it is considered to be a very sensitive age as the patient is a child and cannot understand his/ her disease because of which his consent cannot be taken before any medical treatment. In cases like these, where the patient belongs to the pediatric age group, the consent is to be taken from his parents or legal guardian.

Importance of Consent

Parents are concerned about their child’s health and it is a matter of anxiety for them. Every individual has the right to know about their disease or illness. For pediatric patients, parents should be informed about any improvement or deterioration in their child’s health. Before starting any treatment, proper documentation of the proposed management plan should be done, and it should be signed by the parents or guardian.

There may be legal implications, if a written and duly signed consent is not taken, against the practitioner and the hospital management. It is the duty of Pediatrician to make sure to take informed consent to avoid problems.

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Pediatric Consent Form

A pediatric consent form is different from any other consent form in a way that the patient undergoing treatment is not the one who agrees to the terms and signs it. Parents are anxious about their kids and all the queries from them should be welcomed with empathy. It consists of the following important information:

  • Patient’s information: name, age in years and months, sex, date of birth, father’s name, address, phone number, and blood type.
  • Father’s occupation, work address, phone number, and identity number.
  • History of the patient about both current and past illnesses, surgeries or hospitalization and management.
  • Drug history and allergies if any.
  • History of immunization is stressed upon a lot in pediatric cases.
  • History of breastfeeding.
  • Schooling history; child’s interaction with other kids, academic history and participation in sports.
  • Detailed information regarding the current illness and its management plan. Discussion about all possible treatments, medical or surgical, with their benefits and risks. All frequently asked questions about the disease should be mentioned with answers.
  • A detailed plan of surgery (if any), its advantages and disadvantages. Complications must be thoroughly described.
  • If any anesthesia is to be administered for any procedure, it should be mentioned in the consent form with its form, duration, pros, and cons.
  • The course of follow up and childcare at home.
  • Patient’s privacy and confidentiality agreement.
  • Insurance policy with parents’ social security number.
  • Information about the child’s physician; name, credentials, signature and contact number.
  • A statement stating the acceptance of the medical care, the administration of anesthesia and surgery for the welfare of the child, under the care of the doctor and hospital with full name and signature of parents and/or legal guardian with an identity number.
  • Date and time of consent. Name of the clinic/ hospital.
Pediatric Consent Form Template

Simi Karton

Dr. Simi Karton is a regular contributor to National Science Quarterly and an enthusiastic Lakers fan. She recently collaborated on a manuscript with friends and colleagues. Dr. Simi Karton, entitled Parkinsons and the Genetic Response to Eastern Medicine, in which she and Dr. Inshal presented research compiled during a summer spent in United States. She currently resides in Los Angeles with her husband. This website is a voluntary work of Dr. Karton to provide people with useful health related information stuff at an easy approach. The information has been collected from different sources at one place.

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