Free Child Medical Consent

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Child Medical Consent

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Your Child Medical Consent

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AUTHORIZATION 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 January 23, 2018 at ________________________ and residing at ________________________

  2. I hereby authorize and appoint ____________________ of ________________________ as my agent. My agent may consent to my child's
    1. transportation by ambulance
    2. examination
    3. x-rays
    4. diagnoses
    5. hospitalization
    6. anesthesia
    7. medication

    I do not authorize ____________________ to consent to the transfusion of blood.

  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 23rd 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. 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 ____________________, Alberta this 23rd day of January, 2018.


_________________________________
____________________

 

NOTARY ACKNOWLEDGEMENT

Declared at (city) _______________________ on the 23rd day of January, 2018.

Before me, (Notary's name) _______________________________

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

Address ___________________________

Telephone __________________________

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:

Frequently Asked Questions:

Child Medical Consent FAQ
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