Free Child Medical Consent

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Child Medical Consent

Temporary Caregiver


Temporary Caregiver

Who is the Temporary Caregiver?  What is a Temporary Caregiver?A temporary caregiver is someone who can make medical decisions for the child when the parents or guardians are not available.

Temporary Caregiver

e.g. John Adam Grace

e.g. Street, City, State ZIP Code






Your Child Medical Consent

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AUTHORIZE 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 November 28, 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 28th day of November, 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 ________________, ________.


_________________________________
____________________

 

NOTARY ACKNOWLEDGEMENT


COMMONWEALTH OF VIRGINIA

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: __________________________

Last Updated August 16, 2022

Parents and legal guardians use a Child Medical Consent form to give another person the authority to make medical decisions for their children.

You can customize LawDepot’s Child Medical Consent template to align with your child’s situation and needs. Simply answer a set of questions, then download your document as a PDF or print a hard copy.

A Child Medical Consent form is also known as a:

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

It’s important to use a Child Medical Consent form to authorize medical treatments for your minor child when you’re not there.

For instance, your child may need routine treatments (e.g., asthma inhaler) at daycare or school. Or, they may travel with a sports team or school group and need emergency treatments after an accident.

In any case, if your child isn’t old enough to consent to medical treatments, you’ll likely need to give parental consent.

If caregivers or healthcare professionals act without proper consent, they may face legal consequences (although, some jurisdictions make exceptions in emergencies).

Alternatively, your child’s condition could worsen or cause physical pain while healthcare workers wait for permission to act. 

Good news: a Child Medical Consent form helps prevent these situations.

The legal age for a child to consent to general health care varies by state. However, most states don’t allow people to make these decisions until they reach the legal age of majority (typically between 18 and 21).

If a state allows a minor to consent to medical treatments, they may apply restrictions such as:

  • The minor must show sufficient understanding of the treatment and its consequences
  • The parents or guardians cannot be reached
  • The minor lives apart from their guardians and manages their own financial affairs (i.e., the minor is emancipated)
  • The minor is or was married
  • The minor serves in the military

Parents and legal guardians can use a Child Medical Consent form to grant authority to their child’s temporary caregivers, including:

  • Grandparents or other family members
  • Daycare and childcare providers
  • Sports team coaches
  • Teachers
  • Babysitters
  • Nannies

Most importantly, if you plan to travel without your child or if your child plans to travel without you, it’s a safe bet to create a Child Medical Consent to prepare for emergencies. Give this document to your child’s temporary guardian to use if needed.

Use LawDepot’s Child Medical Consent template to create a document unique to your child and their situation.

1. Provide the personal details of the parties involved

Include the names, contact info, and any important details (e.g., parental custody) about the temporary guardian, the legal guardians, and the child.

2. List your child’s health history and other medical details

If applicable, include details such as:

  • Health insurance coverage
  • Contact info for a family doctor and emergency contact person
  • Any illnesses, medical conditions, allergies, or medication your child has

Specify which emergency and routine treatments you do and do not consent to.

LawDepot’s Child Medical Consent template allows you to:

  • Consent to all treatments
  • Withhold consent to certain treatments (you’ll need to specify which ones)
  • Withhold consent to all treatments

You can also allow (or prohibit) access to your child’s medical and insurance records. For example, you may allow the caregiver to communicate with physicians but prohibit them from viewing insurance claims, lab reports, or x-rays.

Finally, the Child Medical Consent should state when the caregiver’s authority begins and, typically, when it ends. Without an end date, the guardian’s authority continues indefinitely (or until you send a revocation letter to all relevant parties).

In most cases, it’s ideal to notarize a Medical Consent form because it helps ensure your document is legally valid.

A notary public:

  • Verifies the identity of the signing parties
  • Ensures the parties understand the agreement
  • Puts their official stamp or seal on the document

If you don’t plan to notarize your document, LawDepot’s Medical Consent template will have a space for two witnesses to sign. A witness should be an independent third party who has no ties to the parent or child. A temporary caregiver should not be a witness.

Related documents

  • Child Travel Consent: Give your child permission to travel alone or with another guardian.
  • Medical Records Release: Ask a health care provider to release a patient’s medical records to an authorized third party.
  • Separation Agreement: Create a contract to record the terms of a legal separation.
  • Living Will: Also known as a health care directive, use this form to express your personal health care wishes.

Related articles

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