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AUTHORIZE TO CONSENT TO MEDICAL TREATMENT OF CHILD
Information of Child
____________________, male, born April 14, 2021 at ________________________ and residing at __________________________________________
Name: ____________________Address: ________________________Phone Number: ____________________Secondary Phone: ____________________Email: ____________________
IN WITNESS WHEREOF, I hereunto sign my name at ____________________, Virginia this ________ day of ________________, ________.
_____________________________________________________
NOTARY ACKNOWLEDGEMENT
A Child Medical Consent is also known as:
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.
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.
A Child Travel Consent and a Child Medical Consent are documents that serve very different functions. 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.
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.
The following information is contained in a Child Medical Consent:
The Child Medical Consent will be governed by the state where medical services may be sought. Normally this will be where the child resides at the time the parent/guardian cannot give consent.
When choosing a guardian you should consider the following questions:
No. Authorization for medical consent to a temporary guardian does not revoke your parental rights.
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.
Sample
Child Medical Consent
Create Your Child Medical Consent
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