Child Medical Consent

Simply complete the Child Medical Consent form below then click on View Results to see your completed contract.

Use our Child Medical Consent when:

  • You will be traveling and leaving your child or children in the care of others.
  • You want to give consent for your child's caregiver to access emergency medical care for your child.
  • You want a high-quality yet inexpensive Child Medical Consent form.

We regularly maintain this contract. Last Modified: October 2008
Child Medical Consent Details
Check to Show Hints for Completing this Form

This software has the flexibility to let you quickly create the Child Medical Consent you want. It does this by providing many options with appropriate defaults.

Ensure that your information are filled in correctly and completely.
Governing Law

State:
Parents or Guardians
Number of parents or guardians:

Information of Parent/Guardian
Name:
Address:
Town/City:
State:
Zip Code:
Home Telephone Number:
Work Telephone Phone: (Leave blank if none)
Cellular Telephone Phone: (Leave blank if none)
Fax Number: (Leave blank if none)
Other Telephone Phone: (Leave blank if none)
E-mail Address: (Leave blank if none)
Emergency Contact Information of Parents/Guardians
Where can you be contacted in case of emergency?
Select this option if you will not be travelling away from home.
Health Care Treatment

Would you consent to emergency blood transfusion for your child/children?

I authorize my temporary guardian to consent to any of the following health care examinations/treatments for my child/children:

Do you authorize your temporary guardian access to any medical or insurance records related to the health care treatment of your child/children?
Temporary Guardian(s)
Number of temporary guardians

Information of Temporary Guardian
Name:
Address:
City/Town:
State:
Zip Code:
Children
Number of children:

Information of Child
Name:
Address same as parent?
Address:
City/Town:
State:
Zip Code:
Birth Date:
Birthplace: (e.g. "Dallas, Texas" or "Sydney, Australia")
Gender:

Health Insurance Information:
(Policy number, group, plan, etc.)
Child's Blood Type:
Child's Blood Rh Factor:

Is this child currently on medication?

Describe:

Describe any medication this child is currently receiving and why.

Allergies, Illnesses or Other Information?
Is there any other information you think is important? (e.g. name of specialist physician, past illnesses or operations, etc.)

Please describe in the space provided.
Effective Dates

Start Date:
Do you want to specify an end date?
End Date:
Family Physician
Do you want to include contact information for your family doctor?

Name:
Address:
Town/City:
State:
Zip Code:
Telephone Number:
Fax Number: (Leave blank to fill in later)
Emergency Number: (Leave blank to fill in later)
Signing Details
When will this document be signed:
City/Town where document will be signed:
State:
Who will witness your signature?
Note: The temporary guardian or guardians should not be your witnesses.