Free Child Medical Consent

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Create your Child Medical Consent

Information of parent/guardian

Frequently Asked Questions

Who is a guardian?A guardian is an individual who has to right to make decision on behalf of the child. The guardian is generally appointed by local law or court order, or upon the death of a parent through the parent's will to have custody of the child.Do I need both parents signing?Unless there was no father, or one of the parent has died, or you have an order granting full custody, you should have both parents signing the document.
Your Child Medical ConsentUpdate Preview

AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF CHILD

  1. I, ____________________ of ____________________, ____________________, __________, __________, ____________________ make oath and say that I am the lawful guardian of the child listed below and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.

    First Child

    ____________________, male, born December 18, 2014 at ____________________ and residing at ____________________, ____________________, __________, __________, ____________________.


  2. I hereby authorize and appoint ____________________ of ____________________, ____________________, __________  as my agent. My agent may consent to my child's  medical examination or treatment. Such treatment may include but is not limited to the following:
    1. transportation by ambulance
    2. examination
    3. x-rays
    4. diagnoses
    5. hospitalization
    6. anesthesia
    7. medication

    I do not authorize ____________________ to consent to the transfusion of blood.

  3. I give this consent freely and knowingly in order to provide for the child and not as a result of pressure, threats or payments by any person or agency.
  4. This consent will remain in effect until it is revoked by notifying my child's medical, mental health care and insurance providers, in writing, and the agent named above that I wish to revoke it.
  5. Any questions or concerns regarding this authorization may be directed to me at:

    Name: ____________________
    Street Address: ____________________
    City, Province/Territory: ____________________, __________
    Postal Code:
    Country: ____________________

    Home Phone: (______) ______-________
    Work Phone: (______) ______-________
    Cell Phone: (______) ______-________
    Email: ____________________

    Name: ____________________
    Street Address: ____________________
    City, Province/Territory: ____________________, __________
    Postal Code:
    Country: ____________________

    Home Phone: (______) ______-________
    Work Phone: (______) ______-________
    Cell Phone: (______) ______-________
    Email: ____________________


IN WITNESS WHEREOF, I hereunto sign my name at ____________________, __________ this 18th day of December, 2014.


____________________

 

Witness

 

Witness

     

Print Name

 

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