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Information of parent/guardian

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Frequently Asked Questions
Who is a guardian?A guardian is an individual who has to right to make decision on behind 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.
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AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF CHILD

  1. I, ____________________ of ____________________, ____________________, Virginia, __________, ____________________ 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 March 2, 2015 at ____________________ and residing at ____________________, ____________________, Virginia, __________, ____________________.


  2. I hereby authorize and appoint ____________________ of ____________________, ____________________, Virginia __________ 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. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for my child and this power and authority will be effective as of the 2nd day of March, 2015.
  4. 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.
  5. 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.
  6. Any questions or concerns regarding this authorization may be directed to me at:

    Name: ____________________
    Street Address: ____________________
    City, State: ____________________, Virginia
    Zipcode: __________
    Country: ____________________

    Home Phone: __________
    Work Phone: __________
    Cell Phone: __________
    Email: ____________________


IN WITNESS WHEREOF, I hereunto sign my name at ____________________, Virginia this 2nd day of March, 2015.


____________________

  

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Child Medical Consent

Alternate Names:

A Child Medical Consent is also known as:

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

What is a Child Medical Consent?

A Child Medical Consent is a document which allows parents or guardians to authorize another party to consent to their child's medical treatment.

Who should use a Child Medical Consent?

A Child Medical Consent should be used by parents or guardians who may be unable to personally consent to their child's medical treatment due to travel or other situations where the children will be in the care of others.

Frequently Asked Questions:

Q:
What is a Child Medical Consent?
A:
A Child Medical Consent authorizes a caregiver to access medical care for your child without delay. A Child Medical Consent is ideal for use when a child is being cared for by a babysitter, grandparents, or other temporary guardians.
Q:
Do I need a Child Medical Consent if I already have a Child Travel Consent?
A:
A Child Travel Consent and a Child Medical Consent are documents that serve very different functions. It is best to use both documents, so the well being of your child is being looked after comprehensively if your child is traveling with a caretaker in your absence.

A Child Medical Consent authorizes another party to consent to the child's medical treatment.

A Child Travel Consent grants the child the right to travel if one or both of the child's parents/guardians are absent for the child's trip. However, the Child Travel Consent cannot grant consent for the child's medical treatments.

Q:
What information is included in a Child Medical Consent?
A:
The following information is contained in a Child Medical Consent:
  • The names and addresses of the parent(s) or guardian(s) who are providing the authorization;
  • The names and birth dates of all children involved;
  • Health information for each child involved;
  • The identity of the temporary guardian;
  • A description of the medical treatments for which authorization is provided;
  • A statement that there is no court orders that would prevent the parent or guardian from legally making such an authorization; and
  • Signatures of the parent(s) or guardian(s) in the presence of 2 witnesses and a notary public.
Q:
What law governs the Child Medical Consent?
A:
The Child Medical Consent will be governed by the state where medical services may be sought. Normally this will be the where the child resides at the time the parent/guardian cannot give consent.
Q:
How should I choose a temporary guardian?
A:
When choosing a guardian you should consider the following questions:
  • Is the guardian of legal age? In most states a temporary guardian will have to be at least 18 years old in order to consent to medical decisions for your child.
  • Is the guardian genuinely concerned for your child's welfare? You should ensure that your prospective guardian cares for your child's health and well-being.
  • Does the temporary guardian share your moral beliefs? While it is not always necessary to choose a temporary guardian who shares your moral beliefs, you should choose someone who respects and understands your view and who will make medical decisions for your child accordingly.
Q:
Am I giving up my parental rights by using a Child Medical Consent?
A:
No. Authorization for medical consent to a temporary guardian does not revoke your parental rights.
Q:
How do I end the authority of the temporary caregiver?
A:
LawDepot's Child Medical Consent allows you to specify an end date on the form. If you specify an end date, the caregiver's authority will only extend to that date. However, if you do not wish to specify an end date, you can take back a temporary caregiver's responsibilities by telling the temporary caregiver your intentions. If you do this, you should also inform any medical personnel who are acting on the caregiver's authority.

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