PSG Forms Manager - Forms Library: How to create a medical release form that includes the electronic signature field

How to create a medical release form that includes the electronic signature field

Keep in mind that the wording used in this form is just a suggestion taken from other medical release forms.  You can add or remove fields as needed depending on the requirements for your particular program or organization.

 *Attached is a copy of the image used in the creation of this form for your personal use.  Please post credit for the photo in the details of the form to give credit to the artists at Unsplash who provide free-royalty-free photography that can help to enrich and expand the reach of non-profits and small businesses: Photo by CDC on Unsplash

The things that most Medical Release for Minors forms have in common are the following:

  • Name of Parent/Guardian
  • Name of Minor
  • The Actions the form allows the form holder to procure on behalf of the minor or in the Guardian's absence.
  • The Contact of the Primary Parent/Guardian
  • The Name of the Child's PCP or Primary Care Physician and their contact information
  • The name of a preferred hospital in case of hospitalization.
  • Health Insurance Information for the Minor

Using this information, we created the following example of a Medical Release Form for a Minor

  1. Begin with a new form. See, How to create a new form from scratch. The next several steps will walk you through adding these various types of fields to your forms: section header, short text, and static text fields.
    examples_of_shortText_staticText_sectionHeader.png
  2. Once you are in the form, add a section header field with the words: "Parent/Guardian and Student/Child Information"
    2020-08-19_11-57-29.jpg
  3. Next is a series of steps that will add a statement for the user to fill in that grants the church permission to obtain medical treatment for the minor when necessary. See the above image.
    • Add a Static Text field with the words: "This form is to state that I,"
      2020-08-19_11-58-08.jpg
    • Then add a Short Text field and name it Parent or Guardian. Note, you could also use a Name field as found under Contact Info Fields.
      2020-08-19_11-59-04.jpg
    • Add another Static Text field with the words:
      "do hereby grant [CHURCH NAME or PROGRAM] the authority to obtain medical treatment for the following children:"
      2020-08-19_12-01-37.jpg
    • Add another Short Text field for the name of the child or children this form will apply to.  You can also add in a Long Text Field, or a Person Fieldset to add in multiple children if you don't think a short text field will be long enough.
      2020-09-15_9-47-40.jpg
    • Add a new Static Text field that says the following:
      "The [CHURCH NAME or PROGRAM] are authorized to obtain medical treatment and procedures for the child(ren) as may be appropriate in emergency circumstances, including treatment by physicians, hospital and clinic personnel, and other appropriate health care providers, as well as to obtain routine medical treatment from appropriate health care providers if symptoms of illness occur (e.g. fever, coughing, irregular breathing, unusual rashes, swallowing problems, etc.) while said child(ren) are under the care of [CHURCH NAME and PROGRAM] in the city of [CITY, STATE], and I am not reasonably available by telephone to give consent.  This authorization is effective from the date of [START DATE] to [END DATE]."
      2020-09-15_9-48-44.jpg

  4. Add another new Section Header field with the words: "Emergency Contacts"
    2020-09-15_9-49-44.jpg

  5. Under the Emergency Contacts section header, add a new Static Text field with the following:
    "In case of emergency, the care provider(s) should first try to contact the parent(s).  If the parent(s) cannot be reached, then the care provider should contact the following person(s) in the order listed below:"
    2020-09-15_9-50-25.jpg

    The next several steps will walk you through adding Emergency Contact information fields using a Person Field Set with phone, email, and dropdown.
    examples_of_Person_Set_with_phone_email_and_dropdown.png

  6. Add a Person Field Set and set its duplication limit in the field settings to your preferred number of emergency contacts.  This form only allows two emergency contacts.
    2020-09-15_9-54-14.jpg
  7. Drag a Phone Number and an Email field from the Contact Info fields into the Person fieldset. Name each according to their function: Emergency Contact Phone Number and Emergency Contact Email.
    2020-09-15_9-52-46.jpg
  8. Drag a Dropdown field and name it Relationship To The Child with an option to select the contact's relationship to the child.
    2020-03-04_12-21-49.jpg
  9. Add another Static Text field and populate it with the following text:
    "If the child(ren) becomes ill, the care provider(s) will first contact the parent(s).  If the parent(s) cannot be reached, the care provider should contact the following physician:"
    2020-09-15_9-53-29.jpg

    The next several steps will walk you through adding a Person Field Set with phone and address.
    Example_of_ContactInfoFieldsAdderss.png

  10. Add a Person Field Set and name it Physician's information.  This fieldset will not allow duplications.
    2020-03-04_12-31-55.jpg
  11. Drag the following fields into the Person Field Set: Phone number and Address
    2020-03-04_12-33-19.jpg
  12. Next, add another Static Text field with the words: "If the child)ren are in need of hospitalization, the preferred choice is:"
    2020-03-04_12-42-40.jpg
  13. Now add a Basic Fieldset and name it Hospital Information.
    2020-09-15_9-55-38.jpg
    • Into this fieldset, pull in a Short Text field for the Hospital name and one for an Address field.
      2020-03-04_12-50-30.jpg
    • Add one more Static Text field and put the words: "The care provider may provide the physician and other health care providers with the following health insurance information:"
      2020-03-04_13-31-39.jpg

  14. Put in one more Basic Field Set and name it Insurance Information.
    2020-09-15_9-57-13.jpg
    • Drag a Short Text field for the name of the Insurance Company, and another Short Text field for the policy number, with one last Short Text field for the name of the Policyholder.
      2020-03-04_13-35-39.jpg
  15. Last, but not least,  add the Electronic Signature field, so that your Religious Ed parents can give their consent on the form before submitting it.
    2020-03-04_13-38-52.jpg
  16. Save and publish the changes.

When you go to review the responses for the form, the Electronic signatures will look like the following example (ex. raw data):

2020-09-15_9-45-55.jpg

If you require that those filling out the form receive a confirmation of what they've entered, you can add an Email Notification to the form using the following article: How to Add Email Notifications

 


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