I, [Parent’s/Guardian’s Name] being the parents of [Child’s Full Name] authorize [Emergency Contact’s Name] to seek, obtain and consent to for [Child’s Full Name] as deemed necessary by a licensed medical or healthcare professional. This authorization is for the time period when my child is in the care of [Preferred Medical Facility], our child’s [Preferred Medical Facility] and is effective [Guardian’] until revoked by me.

Child’s Information
Name *
Name
Address *
Address
Date of Birth: *
Date of Birth:
Parent/Guardian’s Information
Parent’s/Guardian’s Name: *
Parent’s/Guardian’s Name:
Address: *
Address:
Phone Number (H): *
Phone Number (H):
Phone Number (C): *
Phone Number (C):
Phone Number (W): *
Phone Number (W):
Emergency Contact Person’s Information
Emergency Contact’s Name: *
Emergency Contact’s Name:
Phone Number (H): *
Phone Number (H):
Phone Number (C): *
Phone Number (C):
Phone Number (W): *
Phone Number (W):
Child’s Health Information
Child’s Medical Care Information
Phone Number: *
Phone Number:
Phone Number: *
Phone Number:
Signature of Parent/Guardian
By typing out your name, you are digitally signing this form and in doing so, giving consent as specified above.
Date *
Date

GENERAL INSTRUCTIONS

As a parent or legal guardian, at some point in time, you will likely need to have other people provide care to your minor child. This may include regular daycare, family members who help out occasionally, or perhaps a babysitter for special occasions. When someone else is taking care of your child it is especially important to plan ahead for potential medical needs and emergency situations. A Medical Treatment Authorization and Consent Form allows you to ensure proper medical care is given to your child, even when you cannot be there in person to express your wishes and consent.

WHAT IS A MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM?

A Medical Treatment Authorization and Consent Form specifically identifies the caregivers who are allowed to make medical decisions for your child in your absence, as well as dictating which types of medical decisions can be made by the appointed caregivers. This form will also include other important data, such as your child?s identifying information, your name and contact information, any pertinent medical history, and information regarding your family?s medical providers and medical insurance. Finally, the form includes your signature, the signature of two witnesses, and certification by a notary public.

WHAT SHOULD BE INCLUDED?

- Full legal name of all parents or legal guardians

- Child's full legal name - Caregiver's full legal name (in most states, it will be important that this caregiver is at least 18 years of age)

- Caregiver's relationship to the child (e.g. grandparent, nanny, teacher)

- Types of medical care you are authorizing

- Time period in which this consent will be effective

- Home address for child and parents or legal guardians (if different)

- Child's date of birth and age

- Parent or legal guardian's best contact information

- Child's pertinent medical history which may include health conditions, allergies, medications, and vaccine information

- Names and contact numbers of your child’s regular medical providers which may include pediatricians, dentists, or preferred medical facilities

- Medical insurance information including the name of the insurance company, the policyholder’s name, and the policy/group number.

WHEN SHOULD THIS FORM BE USED?

A Medical Treatment Authorization and Consent Form specifically identifies the caregivers who are allowed to make medical decisions for your child in your absence, as well as dictating which types of medical decisions can be made by the appointed caregivers. This form will also include other important data, such as your child?s identifying information, your name and contact information, any pertinent medical history, and information regarding your family's medical providers and medical insurance. Finally, the form includes your signature, the signature of two witnesses, and certification by a notary public.

WHAT TYPES OF MEDICAL TREATMENT CAN BE SPECIFIED?

You may authorize the caregiver to make decisions about specific types of medical care, including:

- Routine examinations and check ups

- Emergency medical treatment

- Emergency medical transportation

- Diagnostic imaging (x-rays, CT scans, MRIs)

- Medication administration

- Anesthesia and surgical procedures

OTHER NAMES FOR CHILD MEDICAL CONSENT

This form may also be referred to as: Child Medical Consent Form, Caregiver Medical Consent Form, Medical Authorization for Minor, Medical Treatment Authorization Form, Consent for Medical Treatment of a Minor, Authorization to Consent to Medical Treatment.