Child Medical Consent

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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 abroad and leaving your child(ren) in the care of others.
You want to authorize your child(ren)'s caregiver to access emergency medical care for your child(ren).

We regularly maintain this contract. Last Modified: June 2009

Child Medical Consent Details

Parents or Guardians

Number of parents or guardians:

OneTwo

Information of Parent/Guardian

Name:

Address:

City/Town:

State:

ZIP Code:

Home Telephone Number:

Work Telephone Number:

Cellular Telephone Number:

Fax Number:

Other Telephone Number:

E-mail Address:

(Leave field/s blank if none.)

Information of Second Parent/Guardian

Name:

Address same as first parent/guardian?

YesNo

Work Telephone Number:

Cellular Telephone Number:

Fax Number:

Other Telephone Number:

E-mail Address:

Emergency Contact Information of Parents/Guardians

Where can you be contacted in case of emergency?

I can be contacted at home or work

Select this option if you will not be travelling away from home.

I will be away from home

I cannot be contacted

Health Care Treatment

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

YesNo

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

Surgical

Dental

Developmental

Mental Health

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

YesNo

Temporary Guardian(s)

Number of temporary guardians:

OneTwo

Information of Temporary Guardian

Name:

Address:

City/Town:

State:

ZIP Code:

Children

Number of Children:

Information of Child

Name:

Address same as parent?

YesNo

Birthdate:

Age:

Birthplace:

Gender:

MaleFemale

Health Insurance Information:

(e.g. Policy number, group, plan, etc.)

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:

Do you want to specify an end date?

YesNo

Family Physician

Do you want to include contact information for your family doctor?

YesNo

Name:

Address:

City/Town:

State:

ZIP 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.)

Use our Child Medical Consent when:

Parents or Guardians

Information of Parent/Guardian

Information of Second Parent/Guardian

Emergency Contact Information of Parents/Guardians

Second Parent/Guardian

Health Care Treatment

Temporary Guardian(s)

Information of Temporary Guardian

Information of Second Temporary Guardian

Children

Information of Child

Effective Dates

Family Physician

Signing Details

Related Contracts

Frequently Asked Questions

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