UNITED INTERNATIONAL PRIVATE SCHOOL
The First Filipino School and Your Childs Second Home in Dubai
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CONSENT FOR MEDICAL TREATMENT
S.Y. 2022-2023
Name: _______________________________________________________ Grade/Class: _______________
Date of Birth: ____________________________________________
Please Check/ Tick appropriate box:
Please do not give any medication to my child.
I give my consent for the medical staff of United International Private School to give my child the following medicine, if
necessity arises:
Paracetamol (Panadol/Adol) - For fever and pain
Scopinal Syrup/ Buscopan Tablet - For abdominal pain
Claritine Tablet/ Syrup - Anti-allergy
Moxal Suspension/ Tablet - Antacid
Motilium Syrup - For nausea and vomiting
Fludrex Syrup/ Tablet - For nasal congestion/ fever due to common colds
Fucidin Cream/ Ointment - For topical anti-biotic/ treatment of skin infection
Optrex Eye Drops - For eye infection/ inflammation
Reparil Gel - Relief from the minor pain/ stiffness/ muscle soreness
Medijel - Relief from mouth ulcers and gum sores
Axe Oil - For dizziness, abdominal pain and headache (Topical Use)
Calamine Lotion - For itchiness, allergy and insect bites
Prednisolone Sodium Phosphate - For acute treatment of uncontrolled cough, breathlessness
(Predo) and asthma
Pulmicort Nebulization (Budesonide) - For acute asthma attack
Ventolin Nebulization (Salbutamol) - For acute treatment of shortness of breath (dyspnea)
PLEASE NOTE THAT MY CHILD IS:
ALLERGIC TO (PLS. SPECIFY):_________________________________________________________________________________
(Reaction to specific medicines, food and other items that need hospital admission)
SENSITIVE TO (Pls. Specify): _________________________________________________________________________________
(ex. Foods,dust,perfumes, pollens, etc)
_______________________________________ _______________________
Parents Signature over Printed Name DATE
AUTHORIZATION FOR MEDICAL EMERGENCY
In the event parents/guardian cannot be reached through telephone/mobile, I hereby authorize the medical staff and/ or the
school administration of UIPS to make the decision concerning the medical and /or surgical treatment for my child which may
include but not limited to, taking the child to the hospital during emergency cases.
______________________________________ ___________________ ______________
PARENTS SIGNATURE OVER PRINTED NAME CONTACT NUMBER DATE
Student Medical Form
Dear Parent or Guardian of the Student:
Please fill the attached form accurately in order to protect your son or daughter’s health. Photo
If the answer is yes, please write the date and details in comments cell. Accuracy is needed for us
to be able to follow their health status.
Best wishes for good health and wellness
School Information
School Name: United International Private School Grade: ……………………….. Class: ………………………………………..
Student Information
Student Full Name: ………………………………………………………………………… Gender: ………………………………………………..
Date of Birth: ………………………………………………………………… School ID/Reg. No: ……………………………………
Nationality: ……………………………………………………………………….
Fathers Name: ………………………………………………………
Mothers Name: …...................................................................................
Address:…...................................................................................
Emirate: ……………………………………………………………………………..
Mobile Phone Number (1): ……………………. Mobile Phone Number (2): …………………………………………….
Office Phone Number:………………………………..
E-Mail: ……………………………………………………………..
In case of Emergency and not being able to reach parents, the following person can be contacted:
Name: …………………………………………………… Relationship: ……………………… Mobile Phone Number: ….........................................
Required Attachments
Student Emirates ID Yes No ID Number:
…………………………………………………………………………………….
Student Passport Copy Yes No
Original Vaccination Card or
updated colored copy Yes No
(authorized)
Health Card Number (if any) Yes No Health Card Number: …………………………………………………………………..
Health Insurance Card (if any) Health Insurance Card Number: …………………………………………………
Yes No
ID Issue# Issue Date Effective Date Revision Date Page#
CP_6.2.14_F01 01 Jan 01, 2019 Mar 01, 2019 Jan 01, 2021 2/1
Student Medical Form
Medical History of the student
Is there any health problem, out of the following? If the answer is yes, please state the problem type and date in comments cell
Health Problem Yes No Comments
1 Any allergy to drug, food, dust …..
2 Cardiovascular problem
3 Diabetes
4 Hypertension
5 Asthma
6 Renal Problem
7 Epilepsy seizures or Convulsion seizures
8 Epistaxis
9 Hemolytic Anemia, type G6PD
10 Hereditary Blood Disease (e. g. Thalassemia, sickle cell
anemia, Hemophilia), Please specify if any
11 Skin Problem
12 Eye problem (Myopia, Hyperopia, ….), Please specify if any
Is the child wearing eyeglasses?
13 Hearing problem
14 Any case that may weaken Immunity System such as Cancer
(Blood cancer, Lymphoma), or transplantation, Please
specify if any
15 One of the following diseases: (Mumps, Measles,
Diphtheria, Pertussis, Chickenpox, Tuberculosis), Please
specify if any
16 Viral Hepatitis
17 Poliomyelitis (Infantile paralysis infection)
18 Mental of Behavioral Problem, Please specify if any
19 Any other Problem or disease not mentioned here, Please
specify if any
20 Is there a previous exposure to any accident?
21 Is there any previous hospitalization? Please mention the
cause if any
22 Is there any previous exposure to surgery? Please mention
the cause if any
23 Is there any previous blood, antibodies or plasma
transfusion?
24 Was there a need to use any medical aid device? Please
specify if any
ID Issue# Issue Date Effective Date Revision Date Page#
CP_6.2.14_F01 01 Jan 01, 2019 Mar 01, 2019 Jan 01, 2021 3/1
Student Medical Form
Drugs or Treatments taken continuously
Drug Name: ………………………………………………………………………………….. Dosage: …………………………………………………………………………………..
Emergency Drugs
Drug Name: …………………………………………………………………………………. Dosage: ……………………………………………………………………………………
Specific Instructions of the treating doctor regarding Nutrition
…………………………………………………………………………………………………………………………………………………………………………………………………………..
Specific Instructions of the treating doctor regarding exercise and physical activity
………………………………………………………………………………………………………………………………………………………………………………………………………
Specific Instructions of the treating doctor to school nurse to be applied during the school day
................................................................................................................................................................................................................................
Family Health History
Health Problem Yes No Comments
1 Hypertension
2 Diabetes
3 Tuberculosis
4 Mental disorder
5 Stroke
6 Others, specify
Parent or Guardian approval and verification for the above mentioned information
Name of Parent or Legal Guardian: ………………………………………………………………………………………….
Relationship: ………………………………………………………………………………………………………………………………
Signature of the parent or legal Guardian: ……………………………………………………………………………… Date:
……………………………………………………………………………………………………………………………………………
Notes
The parent of legal guardian of the student should fill this form. He or she is responsible for the
abovementioned information.
Medical report about the health problem should be attached.
Parents and Legal Guardians are responsible for informing school nurse about any change that occur in
health status of the student. They should provide the school nurse with the required reports needed to be
added the student health file.
Please contact school nurse or doctor if there is any further queries
ID Issue# Issue Date Effective Date Revision Date Page#
CP_6.2.14_F01 01 Jan 01, 2019 Mar 01, 2019 Jan 01, 2021 4/1
Student Medical Form
Letter for refused vaccination in the school premises
Student Name: ………………………………………………………………………………………………………
Date of Birth: …………………………………………………………………………………………………………
Class/Grade: ………………………………………………………………………………………………………….
School Name: UNITED INTERNATIONAL PRIVATE SCHOOL
I am Mr. / Mrs. .………………………………………………………… (Father/Mother) of
Student……………………………
This is to inform you that I have objection for my son/daughter to receive the vaccination in
the school premises for the reason of
……………………………………………………………………………………………………………………..
I agree & assure to provide the school with a copy of updated vaccination record in regular
basis.
Signature: ………………………………………………………………..
Date: ……………………………………………………………………….
Telephone Number: …………………………………………………
ID Issue# Issue Date Effective Date Revision Date Page#
CP_6.2.14_F01 01 Jan 01, 2019 Mar 01, 2019 Jan 01, 2021 5/1
