School Health General Consent Form

‫ﻧﻤﻮذج ﻣﻮاﻓﻘﺔ ﻋﺎم‬
School Health General Consent Form
Student’s Name: ………………………………... ..............................................................:‫اﺳم اﻟطﺎﻟب‬

School ……………Grade………Class………… ........:‫اﻟﺷﻌﺑﺔ‬.............:‫اﻟﺻف‬...........................: ‫اﻟﻣدرﺳﺔ‬
DOB: ……………………………………………. ........................................................... :‫ﺗﺎرﯾﺦ اﻟﻣﯾﻼد‬
Nationality:…………………...………………… ..................................................................:‫اﻟﺣﻧﺳﯾﺔ‬
ID Number : ............................................ ..................................................:‫رﻗم اﻟﮭوﯾﺔ‬
I the undersigned agree that medical services for my son/ ‫ ﻹﺑﻧﺗﻲ ﻓﻲ ﻋﯾﺎدة‬/‫أﻧﺎ اﻟﻣوﻗﻊ أدﻧﺎه أواﻓق ﻋﻠﻰ ﺗﻘدﯾم اﻟﺧدﻣﺎت اﻟﺻﺣﯾﺔ ﻹﺑﻧﻲ‬
daughter shall be offered in the school’s nurse. .‫ة اﻟﻣدرﺳﺔ‬/‫اﻟﻣدرﺳﺔ ﺑواﺳطﺔ ﻣﻣرض‬
I also agree that these medical services will remain provided to ‫أن ﻣواﻓﻘﺗﻲ ﻋﻠﻰ ھذه اﻟﺧدﻣﺎت اﻟﺻﺣﯾﺔ ﺗﺑﻘﻰ ﺳﺎرﯾﺔ اﻟﻣﻔﻌول ﻟﺣﯾن أﻗوم أﻧﺎ‬
my son / daughter and effective until I refuse these medical .‫ إﺑﻧﺗﻲ ﻓﻲ أي وﻗت أرﻏب ﻓﯾﮫ‬/‫ﺑرﻓض ھذه اﻟﺧدﻣﺎت ﻹﺑﻧﻲ‬
services at any time.
My consent involves a general approval of curative and or ‫أن ﻣواﻓﻘﺗﻲ ﻋﻠﻰ ھذه اﻟﺧدﻣﺎت اﻟﺻﺣﯾﺔ ھﻲ ﻣواﻓﻘﺔ ﻋﺎﻣﺔ ﻋﻠﻰ أي‬
preventive services that may include the following: first aid ‫ ﻗﯾﺎس‬،‫ﺗﻘدﯾم اﻹﺳﻌﺎﻓﺎت اﻷوﻟﯾﺔ‬:‫وﺗﺷﻣل ﻣﺎ ﯾﻠﻲ‬، ‫اﺟراءات وﻗﺎﺋﯾﺔ وﻋﻼﺟﯾﺔ‬
provision , screening for height ,weight , Dental checkup, ‫ إﻋطﺎء اﻟﺗطﻌﯾﻣﺎت ﺑﺈﺷراف ﻣﺑﺎﺷر‬،‫ ﻗﯾﺎس ﺣدة اﻹﺑﺻﺎر‬، ‫اﻟوزن واﻟطول‬
vision acuity , giving vaccination under doctor supervision , ‫ اﻟﺗﺣوﯾﻼت إﻟﻰ أﻗﺳﺎم اﻟطواريء‬،‫ﻓﺣص اﻷﺳﻧﺎن‬، ‫ﻣن طﺑﯾب اﻟﻣدرﺳﺔ‬
and referral to emergency departments at hospitals when ‫ وإﻋطﺎء اﻷدوﯾﺔ اﻟﺗﺎﻟﯾﺔ ﻋﻧد اﻟﺿرورة ﻓﻘط ﻓﻲ ﺣﺎل‬،‫ﻟﻠﺣﺎﻻت اﻟطﺎرﺋﺔ‬
necessary & to administer the following emergency :‫ﺗوﻓرھﺎ ﺑﺎﻟﻌﯾﺎدة‬
medications when needed & available in clinic:
‫اﻟﺑﻧﺎدول أو اﻟﺑروﻓﯾن ﻟﺗﺧﻔﯾف اﻷﻟم اﻟﺧﻔﯾف واﻟﻣﺗوﺳط وﺗﺧﻔﯾض‬.1
1. Paracetamol or Ibuprofen to control mild to moderate pain .‫اﻟﺣرارة‬
and fever. .‫ﻛرﯾم ﻣوﺿﻌﻲ ﻟﻌﻼج اﻟﺣﺳﺎﺳﯾﺔ اﻟﺑﺳﯾطﺔ‬.2
2. Antihistamine cream (topical) for mild allergy. . ‫اﻹﺑﯾﻧﯾﻔرﯾن ﻓﻲ ﺣﺎﻟﺔ اﻟﺣﺳﺎﺳﯾﺔ اﻟﺣﺎدة‬.3
3.Epinephrine in an acute allergic reaction .‫ ﻓﻧﺗوﻟﯾن )ﺳﺎﻟﺑﯾوﺗﺎﻣول ﺑﺧﺎخ( ﻟﻌﻼج أﻋراض اﻟرﺑو‬.4
4.Salbutamol inhaler to control asthmatic symptoms. ‫ﺟﻠوﻛوز )ﺷراب ﯾﺣﺗوي ﻋﻠﻰ اﻟﺳﻛر ﻋن طرﯾق اﻟﻔم( او اﻟﻐﻠوﻛﺎﻏون‬.5
5.Oral glucose(drink contains sugar ) or glucagon for . ‫ﻟﻌﻼج اﻧﺧﻔﺎض ﻣﺳﺗوى اﻟﺳﻛر ﻓﻲ اﻟدم ﻓﻲ ﺣﺎل ﺗوﻓرة‬
hypoglycemia if avialable. ‫اﻟﺑﺳﻛوﺑﺎن ﻟﻌﻼج اﻟﻣﻐص‬.6
6. Hyoscine-N-Butylbromide for colic.
‫اﻟرﺟﺎء ذﻛر اي ﻣواﻧﻊ ﻹﺳﺗﺧدام اﻷدوﯾﺔ أو أي اﺣﺗﯾﺎطﺎت طﺑﯾﺔ ﻋلى‬
Please list any precautions or contraindications to the above :‫ اﻟﻣﻣرﺿﺔ أن ﯾﻌرﻓﮭﺎ‬/‫اﻟﻣﻣرض‬
medications that the school nurse needs to know: ...........................................................................
..................................................................................................... .......................................................................
..................................................................................................... ‫ ﯾرﺟﻰ اﻟﻌﻠم ﺑﺄﻧﮫ ﻟن ﻧﺳﺗطﯾﻊ ﺗﻘدﯾم ھذه اﻟﺧدﻣﺎت‬، ‫ﻓﻲ ﺣﺎل ﻋدم ﻣواﻓﻘﺗﻛم‬
In case of refusal ,the above services will not to be offered ‫ اﺑﻧﺗﻛم ﻟﮭﺎ اﻻ ﻓﻲ اﻟﺣﺎﻻت اﻟطﺎرﺋﺔ اﻟﻘﺻوى اﻟﺗﻰ ﺗﻠزم‬/ ‫ﻋﻧد ﺣﺎﺟﺔ اﺑﻧﻛم‬
except in emergency situations which require immediate . ‫ﺗدﺧﻠﻧﺎ اﻟﺳرﯾﻊ‬
intervention.
‫ اﺑﻧﺗﻲ ﺑﺄي ﺣﺎﻟﺔ طﺎرﺋﺔ ﺗﺳﺗدﻋﻲ اﻟﻧﻘل إﻟﻰ اﻟطواريء‬/ ‫إذا أﺻﯾب اﺑﻧﻲ‬
If my Son/daughter needs to be transferred to the emergency ‫وﻟم أﻛن ﻣﺗواﺟدأ أو ﻣن ﯾﻧوب ﻋﻧﻲ ﻓﺈﻧﻲ أﻋطﻲ اﻟﺻﻼﺣﯾﺔ ﻹدارة اﻟﻣدرﺳﺔ‬
room in either my absence or the legal guardian’s absence, .‫ ﻧﻘﻠﮭﺎ ﺣﺳب اﻟﺣﺎﺟﺔ‬/ ‫ﻟﻧﻘﻠﮫ‬
then I authorize the school to transfer him/her as needed.
I also understand that medical recordis a confidential ‫ ﻟﻠطﺎﻟﺑﺔ وﺛﯾﻘﺔ ﺳرﯾﺔ ﻻ ﯾﺗم ﺗداول اﻟﻣﻌﻠوﻣﺎت‬/ ‫إن اﻟﻣﻠف اﻟﺻﺣﻲ ﻟﻠطﺎﻟب‬
document. .‫اﻟﻣوﺟودة ﺑﮭﺎ اﻻ ﻣن ﻗﺑل أﻋﺿﺎء اﻟﻔرﯾق اﻟطﺑﻲ ﻟوزارة اﻟﺻﺣﺔ‬
Name:...................................................................... .................................................................... : ‫اﻹﺳم‬

Signature of student’s parent/guardian.................... ......................................................... :‫ﺗوﻗﯾﻊ وﻟﻲ اﻷﻣر‬
Relation to the student :......................................... .............................................................. :‫ﺻﻠﺔ اﻟﻘراﺑﺔ‬
Tel # : .................................. ..............................................: ‫رﻗم اﻟﮭﺎﺗف‬
Date :................................... ................................................... :‫اﻟﺗﺎرﯾﺦ‬
Nurse’s Name :..................................ID :.........................

........:‫ اﻟرﻗم اﻟوظﯾﻔﻲ‬.................................:‫اﺳم اﻟم ﻣرض‬

School Health General Consent Form

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‫ﻧﻤﻮذج ﻣﻮاﻓﻘﺔ ﻋﺎم‬

School Health General Consent Form

Student’s Name: ………………………………... ..............................................................:‫اﺳم اﻟطﺎﻟب‬

Name:...................................................................... .................................................................... : ‫اﻹﺳم‬

Nurse’s Name :..................................ID :.........................

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