Free Child Medical Consent

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Child Medical Consent

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Your Child Medical Consent

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AUTHORISATION TO CONSENT TO MEDICAL TREATMENT OF CHILD

  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 20 January 2018 at ________________________ and residing at ________________________

  2. I hereby authorise and appoint ____________________ of ________________________ as my agent. My agent may consent to appropriate medical treatment for my child.
  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 20th day of January, 2018.
  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. I are aware that any costs incurred as a result of injury or illness are my responsibility and I undertake to pay for any medical treatment or advice provided.
  7. 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.
  8. Any questions or concerns regarding this authorisation may be directed to me at:

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

IN WITNESS WHEREOF, I hereunto sign my name at ____________________, Australian Capital Territory this 20th day of January, 2018.


_________________________________
____________________

 

NOTARY ACKNOWLEDGEMENT



Declared at (city) _______________________ on the 20th day of January, 2018.

Before me, (Notary's name) _______________________________

Signature ____________________________________ (Seal)
NOTARY PUBLIC IN AND FOR THE AUSTRALIAN CAPITAL TERRITORY

Address ___________________________

Telephone __________________________

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