Free Child Medical Consent

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Create Your Free Child Medical Consent

  1. Answer a few simple questions
  2. Email, download or print instantly
  3. Just takes 5 minutes

Child Medical Consent

Temporary Caregiver

Temporary Caregiver

Caregiver Details

e.g. Street Address, Locality, City/Town, State, PIN Code

Frequently Asked Questions
Who is a temporary caregiver?The temporary caregiver is someone who can make medical decisions for the child when the parents/guardians are not available.

Your Child Medical Consent

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  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 27 September 2021 at ________________________ and residing at ________________________

  2. I hereby authorise 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. hospitalisation;
    6. anaesthesia;
    7. medication.

    I do not authorise ____________________ 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 27th day of September, 2021.
  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 authorisation may be directed to me at:

    Name: ____________________
    Address: ________________________
    Phone Number: ____________________
    Secondary Phone: ____________________
    Email: ____________________

IN WITNESS WHEREOF, I hereunto sign my name at ____________________,  this ________ day of ________________, ________.




The instrument was acknowledged before me on the ________ day of ________________, ________, by ____________________.

Being satisfied as to the identity of this executant, I hereby subscribe my hand and seal at ____________________________ on this ________ day of ________________, ________.

Notary Public

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