Child Medical Consent (Canada) Form

Child Medical Consent - Details

Parents or Guardians

Number of parents or guardians:

OneTwo

Information of Parent/Guardian

Name:

Address:

City/Town:

Province:

Postal Code:

Home Telephone Number:

Work Telephone Number:

Cellular Telephone Number:

Fax Number:

Other Telephone Number:

E-mail Address:

Leave field(s) blank if none.

Emergency Contact Information of Parents/Guardians

Where can you be contacted in case of emergency?

I can be contacted at home or at work

I will be away from home

I cannot be contacted

Health Care Treatment

Would you consent to emergency blood transfusion for your child(ren)?

YesNo

Do you authorize your temporary guardian access to any medical or insurance records related to the health care treatment of your child(ren)?

YesNo

I authorize my temporary guardian to consent to the following health care examinations/treatments:

Surgical

Dental

Developmental

Mental Health

Your temporary guardian will be authorized to give consent for the examinations or treatments that you select. You may select one or more, or none if you prefer not to authorize.

Temporary Guardian(s)

Number of temporary guardians:

OneTwo

Information of Temporary Guardian

Name:

Address:

City/Town:

Province:

Postal Code:

Children

Number of Children:

Information of Child

Name:

Same address as parent?

YesNo

Birthdate:

Open the calendar popup.

Age:

Birthplace:

(e.g. "Toronto, Ontario" or "Sydney, Australia")

Gender:

MaleFemale

Health Insurance Information:

Enter insurance policy number, group, plan, etc.

Medical History

Child's Blood Type:

Child's Blood Rh Factor:

NegativePositiveUnsure

Is this child currently on medication?

YesNo

Allergies, Illnesses or Other Information?

YesNo

Effective Dates

Start Date:

Open the calendar popup.

Do you want to specify an end date?

YesNo

Family Physician

Include contact information for your family doctor?

YesNo

Name:

Address:

City/Town:

Province:

Postal Code:

Telephone Number:

Fax Number:

Emergency Number:

Signing Details

When will this document be signed?

City/Town where document will be signed:

Where will first parent/guardian sign the document:

Who will witness your signature?

The temporary guardian or guardians should not be your witnesses.

Child Medical Consent - Canada

Protect your children.

Parents or Guardians

Information of Parent/Guardian

Information of Second Parent/Guardian

Emergency Contact Information of Parents/Guardians

Contact Information for First Parent/Guardian

Second Parent/Guardian

Contact Information for Second Parent/Guardian

Health Care Treatment

Temporary Guardian(s)

Information of Temporary Guardian

Information of Second Temporary Guardian

Children

Information of Child

Medical History

Effective Dates

Family Physician

Signing Details

Background and Further Reading

Related Contracts

Common Options

Open from LawDepot

Save & View

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