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

Effective Date

Effective Date

When will this consent be valid?

Frequently Asked Questions
What is the start date?The start date is the date which the consent becomes effective and the temporary caregiver can begin to make medical decisions on behalf of the child.What is the end date?The end date is the date which the consent expires and the temporary caregiver will no longer have the power to make medical decisions on behalf of the child. If no end date is selected, the temporary caregiver will continue to have power indefinitely until the parent/guardian revokes it with a written notice to the proper parties.How do I end the authority of the temporary caregiver if I don't specify an end date?The parent/guardian may end the consent at any time by notifying the child's medical and insurance providers in writing that they wish to revoke the consent granted to the temporary caregiver.

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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