Free Child Medical Consent

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Create Your Free Child Medical Consent

Answer a few simple questions
Email, download or print instantly
Just takes 5 minutes

Child Medical Consent

Effective Date

When will the caregiver's authority begin?

Start date:What happens on 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.

Do you want to list an end date? What happens on the end date?The end date is the date which the consent expires, after which 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.

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Frequently Asked Questions

How do I end the authority of the temporary caregiver if I don't specify an end date?To revoke a consent early or without a specified end date, send a revocation letter to any medical or insurance providers that received a copy of the original consent letter.

Your Child Medical Consent

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AUTHORIZE TO CONSENT TO MEDICAL TREATMENT OF CHILD

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 May 29, 2022 at ________________________ and residing at __________________________________________
I hereby authorize and appoint ____________________ of __________________________________________ as 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.
My Agent may have access to any and all records, including, but not limited to, insurance records regarding any medical services or treatment provided.
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 29th day of May, 2022.
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.
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.
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 ____________________, Virginia this ________ day of ________________, ________.

_________________________________
____________________

NOTARY ACKNOWLEDGEMENT

COMMONWEALTH OF VIRGINIA

COUNTY OF ______________

I ____________________________, a Notary Public in and for the said County and State, hereby certify that ____________________, having signed this Child Medical Consent, and being known to me (or whose identity has been proven on the basis of satisfactory evidence), acknowledged before me on this day that, being informed of the contents of the conveyance, the Parent1 has executed this Child Medical Consent voluntarily and with lawful authority.

Given under my hand and seal, this ________ day of ________________, ________.

_______________________________
Notary Public for the Commonwealth of Virginia

County of _________________________

My commission expires: __________________________

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Child Medical Consent Form

Alternate Names:

A Child Medical Consent is also known as a:

Child Medical Release Form

Caregiver Consent Form

Consent for Medical Treatment of a Minor

Medical Treatment Authorization Form

What is a Child Medical Consent form?

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.

Who should use a Child Medical Consent form?

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:

The parents or guardians are away from home for an extended period of time for work or travel
The children are traveling alone or with a chaperone who is not a parent or guardian

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:

Grandparent
Aunt or uncle
Family friend
Babysitter
Daycare

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.

How do I choose a temporary guardian?

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:

Cares about your children's health and well-being
Shares (or respects) your moral beliefs pertaining to medical care
Acts responsibly and is a good role model when around your children
Has experience in caring for children for long periods of time

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.

Do I need a Child Medical Consent form and a Child Travel Consent form?

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.

What should I include in my Child Medical Consent?

A Child Medical Consent should include:

Information about the parent or guardian, including their name, phone number, address, and any pertinent details regarding parental custody (such as if one parent has sole custody)
Information about the child, including their name and birthdate
Information about the temporary guardian, such as their name and phone number
Health information for each child named in the document, including medication, illnesses, allergies, special needs, and the particulars regarding their health insurance
A list of medical treatments you would allow the caretaker to consent to in your absence if required (for instance, a blood transfusion or a surgery)

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.

When does a Child Medical Consent form end?

A Child Medical Consent form ends by:

Including an end date in your document
Informing the caregiver that their consent is revoked (typically in writing)

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.