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Child Medical Consent



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 February 25, 2024 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 25th day of February, 2024.
  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 ________ day of ________________, ________.




Declared at (city) _______________________ on the ________ day of ________________, ________.

Before me, (Notary's name) _______________________________

Signature ____________________________________ (Seal)

Address ___________________________

Telephone __________________________

Last Updated January 31, 2024

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

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.

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.

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.

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.

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.

Related Documents:

  • Child Travel Consent: a document that grants a child permission to travel with a temporary guardian in the absence of the child's parents
  • Last Will and Testament: an estate planning document that allows you to determine how your assets are distributed after you pass away
  • Living Will: an estate planning document that allows you to voice your end-of-life medical preferences and name someone to make medical decisions on your behalf if you become incapacitated
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Child Medical Consent

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