Free Child Medical Consent

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Create Your Free Child Medical Consent

Answer a few simple questions
Email, download or print instantly
Just takes 5 minutes

Child Medical Consent

Effective Date

When will the caregiver's authority begin?

Start date:The start date is the date which the consent becomes effective and the temporary caregiver can begin to make medical decisions on behalf of the child.

Do you want to list an end date? The end date is the date which the consent expires and the temporary caregiver will no longer have the power to make medical decisions on behalf of the child. If no end date is selected, the temporary caregiver will continue to have power indefinitely until the parent/guardian revokes it with a written notice to the proper parties.

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Frequently Asked Questions

How do I end the authority of the temporary caregiver if I don't specify an end date?To revoke a consent early or without a specified end date, send a revocation letter to any medical or insurance providers that received a copy of the original consent letter.

Your Child Medical Consent

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AUTHORIZE TO CONSENT TO MEDICAL TREATMENT OF CHILD

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 April 18, 2021 at ________________________ and residing at __________________________________________
I hereby authorize and appoint ____________________ of __________________________________________ as 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.
My Agent may have access to any and all records, including, but not limited to, insurance records regarding any medical services or treatment provided.
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 18th day of April, 2021.
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.
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.
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 ____________________, Alberta this ________ day of ________________, ________.

_________________________________
____________________

NOTARY ACKNOWLEDGEMENT

Declared at (city) _______________________ on the ________ day of ________________, ________.

Before me, (Notary's name) _______________________________

Signature ____________________________________ (Seal)
NOTARY PUBLIC IN AND FOR THE PROVINCE OF ALBERTA

Address ___________________________

Telephone __________________________

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Child Medical Consent Information

Alternate Names:

A Child Medical Consent is also known as a:

Medical Authorization Form

Consent For Medical Treatment of a Minor

Parental Consent Form

Medical Authorization Letter for a Child

What is a Child Medical Consent form?

A Child Medical Consent form is used by parents or legal guardians of minor children to give another adult authority over their child's medical treatment.

LawDepot's Child Medical Consent can be used in all provinces and territories excluding Quebec.

When should I use a Child Medical Consent?

A Medical Authorization Form can be used when a child is away from their parent or guardian and in the care of a temporary caregiver. Some common instances may be when:

Travelling with someone other than a parent/guardian
In the care of a babysitter, day home, or daycare
During school, field trips, or recreational activities (sports clubs, organizations, or youth groups)
Staying with relatives, such as grandparents, aunts, uncles, etc.

What information does Child Medical Consent form need?

To complete your medical consent form, you will need to provide the following:

Parent and child contact information
Child medical information, including medications, illnesses, allergies, or health insurance details
Contact information for temporary caregiver (e.g. relative, babysitter, teacher, etc.)
When the consent form becomes effective
An end date if you'd like to specify when the consent expires
Decision-making powers given to the temporary caregiver
Name of your family physician (optional)

What health care powers can I give to a temporary guardian?

As the parent, you can choose which medical treatments and examinations to authorize and which not to authorize, including:

Blood transfusion
Surgery
Dental
Developmental: refers to treatment of cognitive, social, or physical development of a child
Mental Health: care relating to a child's psychological or emotional health

You can also choose whether or not to give the caregiver access to your child's medical records or health insurance.

What is the difference between a Child Medical Consent and a Child Travel Consent?

A Child Medical Consent form is used to grant authority over your child's medical treatment to another caregiver.

A Child Travel Consent is used by parents to give permission for a child to travel with another adult, alone, or with a group.

Who signs a Child Medical Consent form?

Both parents/guardians should sign the authorization form. If one parent has passed away or one parent has sole custody, it is the custodial parent who should sign the document. It is recommended that there be at least two witnesses or a notary public to witness the document's execution.

Forms Related to a Child Medical Consent:

Child Travel Consent: a document that grants a child permission to travel with a temporary guardian in the absence of the child's parents

Last Will and Testament: an estate planning document that allows you to determine how your assets are distributed after you pass away

Living Will: an estate planning document that allows you to voice your end-of-life medical preferences and name someone to make medical decisions on your behalf if you become incapacitated

Frequently Asked Questions:

Child Medical Consent FAQ