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Child Medical Consent

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Your Child Medical Consent

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AUTHORIZE 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 July 24, 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 24th day of July, 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 ________________, ________.


_________________________________
____________________

 

NOTARY ACKNOWLEDGEMENT

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

Before me, (Notary's name) _______________________________

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

Address ___________________________

Telephone __________________________

Last Updated March 12, 2024

Written by 

Reviewed by 


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Fact checked by 



A Child Medical Consent form is a document parents or guardians create to give another adult authority over their child’s medical treatment. It allows a temporary caregiver to make decisions for a child’s medical care if their parent or guardian isn’t available for any reason. 

A Child Medical Consent form is also known as a:

  • Child medical authorization form
  • Consent for medical treatment of a minor
  • Letter for medical consent

Please note that LawDepot’s Child Medical Consent template is available for all provinces and territories except Quebec.

In case of incapacitation, parents and guardians can use a Living Will, also known as an Advance or Personal Directive, to give another adult authority over their own medical treatment.

A Child Medical Consent form is an essential document for parents. It gives someone else medical authority if anything occurs in your absence. It does not revoke any of your parental rights. Instead, it ensures your child always has access to necessary medical care in case of emergencies or if your child has medical needs when you’re apart. 

Examples of when to use a Child Medical Consent form can be when your minor child:

  • Travels with other family members or adults
  • Participates in recreational activities (e.g., sports, clubs, youth groups, etc.)
  • Is being cared for by a babysitter, daycare, or day home
  • Is staying with other family members
  • Goes on a school trip

In most medical situations, doctors will only treat a child if a parent or guardian is present to consent to treatment. So, this consent allows a caregiver to consent on your behalf if you’re unavailable. The only exception may be in the case of an emergency, depending on the jurisdiction. For example, in Ontario’s Health Care Consent Act, doctors may perform emergency medical treatment if obtaining consent will prolong the severe suffering of the patient or cause bodily harm.

In Canada, children are often presumed mature enough to give medical consent at the age of 16, but medical personnel consider this on a case-by-case basis. Some provinces and territories have additional legislation on determining a child’s capability and age to consent to medical care. 

For example, New Brunswick’s Medical Consent of Minors Act acknowledges that minors who are 16 years old may consent to medical treatment. Anyone under the age of 16 may also consent to medical treatment if they understand the nature and consequences of the treatment. They also must be able to make a decision that is in their best interest, continued health, and well-being. 

In contrast, Alberta doesn't have additional legislation about determining a child's capability and age to consent to medical care.

When creating a Child Medical Consent, you can choose whether your child’s caregiver may consent to some or all routine and emergency medical treatments. Types of medical treatment could include:

  • Anaesthesia
  • Surgical procedures
  • Blood transfusions
  • Mental healthcare
  • Diagnostic procedures, such as scans and x-rays
  • Immunizations
  • Dentistry

You can also choose whether or not to give the caregiver access to your child's medical records, health insurance, or healthcare card.

Using LawDepot’s user-friendly questionnaire lets you create your Child Medical Consent form by completing the following steps:

1. Appoint a caregiver

Include the name and address of the temporary caregiver. If you like, there can be more than one person you give this authority to. Just be sure to include both their names and details on your form. Common choices for temporary caregivers include: 

  • Grandparents or other family members
  • Daycare or childcare providers
  • Nannies or babysitters
  • Teachers
  • Coaches

2. Give parent or guardian details

Provide your name(s) and address(es). Your consent form should include both parents, if applicable. If one parent has passed, or you have full custody, then you only need to complete and sign this section.

3. Provide your child’s details

When you’re providing your child’s name, you’ll need to include a complete description of the following information:

  • Gender
  • Date and place of birth
  • Address
  • Medical details (i.e., illnesses, conditions, allergies, medications, etc.)

Some optional details you can add to your consent form include:

  • Any health insurance or healthcare card
  • A current family doctor (if applicable)
  • Emergency contact details

Next, you need to outline what authority you’re giving your child’s temporary caregiver. You’ll need to consider the following questions:

  • Can they consent to emergency or routine medical treatments?
  • Can they access your child’s medical records?

Your consent will include diagnostic and surgical procedures, dental treatment, and blood transfusions unless you state otherwise on your form. Please list in detail anything you do not wish your temporary caregiver to authorize in your absence.

5. Specify when the authority begins 

When you create your Child Medical Consent form, you can choose when the consent will start and decide if it will have a specific end date. For example, you can create a limited time of consent if your child travels without you by simply setting the day they return home as the end date.

If no end date is selected, your temporary caregiver can continue to have the authority until you revoke it with a written notice to them and any other parties that need to know, such as your family doctor. 

6. Signing details

Provide the signing date and the location where you’ll sign your consent form. If you wish to have it notarized, our template allows you to select that option for your final document.

Both parents or guardians, if applicable, should authorize the consent by signing the completed form.

There’s no legal requirement to have your Child Medical Consent form notarized. That being said, notarization is never a bad idea. It further validates your requests and authorization should a temporary caregiver need to provide medical consent for your child.

Alternatively, you can have two witnesses present when signing the document. In this case, your child’s nominated caregiver(s) cannot act as witnesses.

Related Documents:

  • Child Travel Consent: Create a document granting your child permission to travel with a temporary guardian in your absence.
  • Last Will and Testament: Write an estate planning document determining how to distribute your assets after you pass away.
  • Living Will: Write an estate planning document detailing your end-of-life medical preferences and naming someone to make medical decisions on your behalf if you become incapacitated.
  • Child Care Contract: Create a contract between you and a childcare provider to outline your arrangements.
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