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AUTHORIZE TO CONSENT TO MEDICAL TREATMENT OF CHILD
Information of Child
____________________, male, born May 29, 2022 at ________________________ and residing at __________________________________________
Name: ____________________Address: ________________________Phone Number: ____________________Secondary Phone: ____________________Email: ____________________
IN WITNESS WHEREOF, I hereunto sign my name at ____________________, Virginia this ________ day of ________________, ________.
_____________________________________________________
NOTARY ACKNOWLEDGEMENT
A Child Medical Consent is also known as a:
A Child Medical Consent form is used when parents or guardians want to give another person (a temporary guardian) the authority to make medical decisions for their children.
Generally, this form is used by parents or guardians in instances when they will be unable to consent to medical treatment for their children for a specific period of time.
A Child Medical Consent form should be used when parents or guardians are unable to consent to medical treatment for their children and wish to grant the authority to a temporary guardian.
For instance, a Child Medical Consent may be used if:
A Child Medical Consent can also be used when a child is staying with someone who is not a parent or guardian for an extended period, such as a/an:
It may also be beneficial to provide a Child Medical Consent form to a live-in caretaker (like a nanny or au pair), in case your children require medical care while under their supervision.
In most states, a temporary guardian should be at least 18 years old in order to make medical decisions for your child.
In addition, an appropriate temporary guardian:
You may also want to consider other factors, like if they live in a different city or state than you, if they have any children or pets, or whether your children are comfortable around this person.
A Child Medical Consent form and a Child Travel Consent form serve different purposes.
A Child Travel Consent form allows your children to travel without you or their primary guardian. Travel consent is typically provided to a caregiver but may also be used when children are traveling alone.
Because a Child Medical Consent form allows a caregiver to make medical decisions and a Child Travel Consent does not, it's recommended that you complete both documents when the children are traveling without you.
A Child Medical Consent should include:
It is recommended that you include a start and end date, if known, so that the temporary caretaker is unable to make medical decisions for your children when you are available to do so.
A Child Medical Consent form ends by:
Including an end date on your Child Medical Consent form, if possible, is recommended so the document automatically ends when it's no longer needed.
Without an end date, the guardian you chose is able to consent to medical treatments for your children indefinitely.
If you decide to revoke your caregiver's consent manually, you should provide notice to medical personnel, like your family doctor or hospital staff, to advise them of the change in consent.
Sample
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