Declaration of Parental Responsibility

Adult's Personal Details

1. Please enter your Full Name including any middle names: *

First Name	*
Middle Name
Surname	*

2. Please enter your full Postal Address: *

First Line of Address	*
Second Line of Address
Town/City	*
Postcode	*

3. Please enter your Date of Birth: *

	DD/MM/YYYY
DOB:

4. Please enter your email address: *

5. Please enter your phone number: *

Declaration of Parental Responsibility

6. Please enter the Child's name including any middle names: *

First Name	*
Middle Name
Surname	*

7. Child's Date of Birth: *

	DD/MM/YYYY

8. Names of People with Parental Responsibility: *

9. Names of others authorised to bring the above named child for treatment at EdgCARE:

I confirm that I have parental responsibility for the above-named child and that I am happy that my child be treated if accompanied by any of the above-named people. I confirm that I will inform the surgery in the event of any change.
Please enter your name below to confirm this: *

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