Free Child Medical Consent

Free Child Medical Consent

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Child Medical Consent

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Child Medical Consent

Create Your Child Medical Consent

Create Your Child Medical Consent

Frequently Asked Questions
What is a Child Medical Consent?A Child Medical Consent form is used by parents or guardians of minor children to grant authorization for another adult, such as a grandparent or child care provider, to make medical decisions for the minor child on their behalf.Who is a guardian?A guardian is an individual who has the right to make decisions on behalf of the child. The guardian is generally appointed by local law or court order, or by a deceased parent's will.Do both parents/guardians need to sign this Child Medical Consent form?Both parents should sign the Child Medical Consent form unless it is a single parent family or one parent has full custody of the minor.

Your Child Medical Consent

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AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF CHILD

  1. We, ____________________ and ____________________ of ____________________, ____________________, Manitoba, Canada, __________ make oath and say that we are the lawful guardians of the child listed below and there are no court orders now in effect that would prohibit us from conferring the power to consent upon another person.

    Information of Child

    ____________________, male, born February 23, 2017 at ____________________ and residing at ____________________, ____________________, Manitoba, Canada, __________.


  2. We hereby authorize and appoint ____________________ of ____________________, ____________________, Manitoba, Canada, __________, as our agent. Our agent may consent to our child's surgical, dental, developmental, mental health and/or
    1. transportation by ambulance
    2. examination
    3. x-rays
    4. diagnoses
    5. hospitalization
    6. anesthesia
    7. surgery
    8. medication
    9. transfusion of blood or blood products

    Our agent may have access to any and all records, including, but not limited to, insurance records regarding any such services.

  3. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for our child and this power and authority will be effective as of the 23rd day of February, 2017.
  4. We 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 our child's medical, mental health care and insurance providers, in writing, and the agent named above that we wish to revoke it.
  6. Any questions or concerns regarding this authorization may be directed to us at:

    Name: ____________________
    Street Address: ____________________
    City, Province/Territory: ____________________, Manitoba
    Postal Code: __________

    Phone Number: __________
    Secondary Phone: __________
    Email: ____________________

    Name: ____________________
    Street Address: ____________________
    City, Province/Territory: ____________________, Manitoba
    Postal Code: __________

    Phone Number: __________
    Secondary Phone: __________
    Email: ____________________

IN WITNESS WHEREOF, we hereunto sign our names at ____________________, Manitoba this 23rd day of February, 2017.


____________________

 

____________________

Witness

 

Witness

     

Print Name

 

Print Name


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.

Information Needed in a Child Medical Consent:

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.

Child Medical Consent vs. 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:

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