Free Child Medical Consent

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Child Medical Consent



Your Child Medical Consent

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  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.

    Information of Child

    ____________________, male, born August 10, 2022 at ________________________ and residing at __________________________________________

  2. I hereby authorize and appoint ____________________ of __________________________________________ as my agent (my "Agent"). Unless otherwise provided in this authorization, my Agent may consent to emergency and routine medical treatment for my child, including dental treatment, anaesthesia, and blood transfusion.
  3. My Agent may have access to any and all records, including, but not limited to, insurance records regarding any medical services or treatment provided.
  4. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for my child. This power and authority will be effective as of the 10th day of August, 2022.
  5. I give this consent freely and knowingly in order to provide for the child and not as a result of coercion, duress or payments by any person or agency.
  6. 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.
  7. Any questions or concerns regarding this authorization may be directed to me at:

    Name: ____________________
    Address: ________________________
    Phone Number: ____________________
    Secondary Phone: ____________________
    Email: ____________________

IN WITNESS WHEREOF, I hereunto sign my name at ____________________, Virginia this ________ day of ________________, ________.





COUNTY OF ______________

I ____________________________, a Notary Public in and for the said County and State, hereby certify that ____________________, having signed this Child Medical Consent, and being known to me (or whose identity has been proven on the basis of satisfactory evidence), acknowledged before me on this day that, being informed of the contents of the conveyance, the Parent1 has executed this Child Medical Consent voluntarily and with lawful authority.

Given under my hand and seal, this ________ day of ________________, ________.

Notary Public for the Commonwealth of Virginia

County of _________________________

My commission expires: __________________________

Child Medical Consent Form

Alternate Names:

A Child Medical Consent is also known as a:

  • Child Medical Release Form
  • Caregiver Consent Form
  • Consent for Medical Treatment of a Minor
  • Medical Treatment Authorization Form

What is a Child Medical Consent form?

A Child Medical Consent form is used when parents or guardians want to give another person (a temporary guardian) the authority to make medical decisions for their children.

Generally, this form is used by parents or guardians in instances when they will be unable to consent to medical treatment for their children for a specific period of time.

Who should use a Child Medical Consent form?

A Child Medical Consent form should be used when parents or guardians are unable to consent to medical treatment for their children and wish to grant the authority to a temporary guardian.

For instance, a Child Medical Consent may be used if:

  • The parents or guardians are away from home for an extended period of time for work or travel
  • The children are traveling alone or with a chaperone who is not a parent or guardian

A Child Medical Consent can also be used when a child is staying with someone who is not a parent or guardian for an extended period, such as a/an:

  • Grandparent
  • Aunt or uncle
  • Family friend
  • Babysitter
  • Daycare

It may also be beneficial to provide a Child Medical Consent form to a live-in caretaker (like a nanny or au pair), in case your children require medical care while under their supervision.

How do I choose a temporary guardian?

In most states, a temporary guardian should be at least 18 years old in order to make medical decisions for your child.

In addition, an appropriate temporary guardian:

  • Cares about your children's health and well-being
  • Shares (or respects) your moral beliefs pertaining to medical care
  • Acts responsibly and is a good role model when around your children
  • Has experience in caring for children for long periods of time

You may also want to consider other factors, like if they live in a different city or state than you, if they have any children or pets, or whether your children are comfortable around this person.

Do I need a Child Medical Consent form and a Child Travel Consent form?

A Child Medical Consent form and a Child Travel Consent form serve different purposes.

A Child Travel Consent form allows your children to travel without you or their primary guardian. Travel consent is typically provided to a caregiver but may also be used when children are traveling alone.

Because a Child Medical Consent form allows a caregiver to make medical decisions and a Child Travel Consent does not, it's recommended that you complete both documents when the children are traveling without you.

What should I include in my Child Medical Consent?

A Child Medical Consent should include:

  • Information about the parent or guardian, including their name, phone number, address, and any pertinent details regarding parental custody (such as if one parent has sole custody)
  • Information about the child, including their name and birthdate
  • Information about the temporary guardian, such as their name and phone number
  • Health information for each child named in the document, including medication, illnesses, allergies, special needs, and the particulars regarding their health insurance
  • A list of medical treatments you would allow the caretaker to consent to in your absence if required (for instance, a blood transfusion or a surgery)

It is recommended that you include a start and end date, if known, so that the temporary caretaker is unable to make medical decisions for your children when you are available to do so.

When does a Child Medical Consent form end?

A Child Medical Consent form ends by:

  • Including an end date in your document
  • Informing the caregiver that their consent is revoked (typically in writing)

Including an end date on your Child Medical Consent form, if possible, is recommended so the document automatically ends when it's no longer needed.

Without an end date, the guardian you chose is able to consent to medical treatments for your children indefinitely.

If you decide to revoke your caregiver's consent manually, you should provide notice to medical personnel, like your family doctor or hospital staff, to advise them of the change in consent.

Related Documents:

  • Child Travel Consent: a form used by a parent or guardian that provides consent for their child to travel without them
  • Medical Records Release: a form giving permission to transfer your health records to a third party
  • Cohabitation Agreement: a contract between an unmarried couple who wishes to live together and combine their finances
  • Separation Agreement: a contract containing the terms and conditions of a married couple's legal separation

Related Articles:

Frequently Asked Questions:

Child Medical Consent FAQ
Child Medical Consent Sample


Child Medical Consent

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