Pediatric Consent Form

September 13, 2019

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 this, his consent cannot be obtained before any medical treatment. In cases like these, where the patient belongs to the pediatric age group, consent is to be obtained 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 written and duly signed consent is not obtained, against the practitioner and the hospital management. The pediatrician must make sure to obtain informed consent to avoid problems.

Pediatric Consent Form

A pediatric consent form is different from any other consent form in a way that the patient undergoing treatment does not agree to the terms and signs them. Parents are anxious about their kids, and all their queries 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.
The history of immunization is stressed a lot in pediatric cases.
History of breastfeeding.
Schooling history; a 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 the parents’ social security number.
Information about the child’s physician: name, credentials, signature, and contact number.
A statement stating the acceptance of medical care, the administration of anesthesia, and surgery for the welfare of the child under the care of the doctor and hospital with the full name and signature of the parents and/or legal guardian with an identity number.
Date and time of consent. Name of the clinic or hospital.