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Medical consent

Thank you for your commitment to becoming a foster carer with Brophy Family and Youth Services. As part of your assessment, it is a prerequisite that prospective foster carers be of sufficiently good mental, emotional and physical health to care for a child or young person. A two-part medical report is required:

Part one - Applicant health checklist (completed by you) Part two - Medical questionnaire (completed by your doctor)

Once you submit this form, we will send the medical questionnaire directly to the doctor you nominate below. Your doctor may ask you to attend an appointment before completing it - this will be an arrangement between you and your doctor.

Please note: each applicant must complete a separate medical consent form. If there are two applicants in your household, please ensure both individuals submit their own form.

Applicant details

Full legal name

Email address

Doctor details

Name of doctor

Address

Phone number

Email address

Consent and declaration

Untitled checkboxes field

I consent to the release of medical information held by my doctor nominated above.

Untitled checkboxes field

I declare that I have answered the applicant health checklist truthfully, and I undertake to advise Brophy, now and in the future, of any information or knowledge I have which may relate to current or future medical conditions.

Full legal name

Signature