Free Child Medical Consent

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Child Medical Consent

Effective Date

Effective Date

When will the caregiver's authority begin?

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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  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 November 27, 2021 at ________________________ and residing at __________________________________________

  2. 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.
  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 November, 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 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 ________________, ________.





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: __________________________

Child Medical Consent

Alternate Names:

A Child Medical Consent is also known as:

  • Medical Authorization for a Minor
  • Child Medical Release Form
  • Medical Consent for Minors
  • Caregiver Consent Form

What is a Child Medical Consent?

A Child Medical Consent authorizes a caregiver to access medical care for your child without delay. A Child Medical Consent is ideal for use when a child is being cared for by a babysitter, grandparents, or other temporary guardians.

Who should use a Child Medical Consent?

A Child Medical Consent should be used by parents or guardians who may be unable to personally consent to their child's medical treatment due to travel or other situations where the children will be in the care of others.

Do I need a Child Medical Consent if I already have a Child Travel Consent?

A Child Travel Consent and a Child Medical Consent are documents that serve very different functions. A Child Medical Consent authorizes another party to consent to the child's medical treatment. A Child Travel Consent grants the child the right to travel if one or both of the child's parents/guardians are absent for the child's trip. However, the Child Travel Consent cannot grant consent for the child's medical treatments.

It is best to use both documents, so the well being of your child is being looked after comprehensively if your child is traveling with a caretaker in your absence.

What information is included in a Child Medical Consent?

The following information is contained in a Child Medical Consent:

  • The names and addresses of the parent(s) or guardian(s) who are providing the authorization;
  • The names and birth dates of all children involved;
  • Health information for each child involved;
  • The identity of the temporary guardian;
  • A description of the medical treatments for which authorization is provided;
  • A statement that there is no court orders that would prevent the parent or guardian from legally making such an authorization; and
  • Signatures of the parent(s) or guardian(s) in the presence of 2 witnesses and a notary public.

What law governs the Child Medical Consent?

The Child Medical Consent will be governed by the state where medical services may be sought. Normally this will be where the child resides at the time the parent/guardian cannot give consent.

How should I choose a temporary guardian?

When choosing a guardian you should consider the following questions:

  • Is the guardian of legal age? In most states a temporary guardian will have to be at least 18 years old in order to consent to medical decisions for your child.
  • Is the guardian genuinely concerned for your child's welfare? You should ensure that your prospective guardian cares for your child's health and well-being.
  • Does the temporary guardian share your moral beliefs? While it is not always necessary to choose a temporary guardian who shares your moral beliefs, you should choose someone who respects and understands your view and who will make medical decisions for your child accordingly.

Am I giving up my parental rights by using a Child Medical Consent?

No. Authorization for medical consent to a temporary guardian does not revoke your parental rights.

How do I end the authority of the temporary caregiver?

LawDepot's Child Medical Consent allows you to specify an end date on the form. If you specify an end date, the caregiver's authority will only extend to that date.

However, if you do not wish to specify an end date, you can take back a temporary caregiver's responsibilities by telling the temporary caregiver your intentions. If you do this, you should also inform any medical personnel who are acting on the caregiver's authority.

Related Documents:

  • Child Travel Consent: a form used by a parent or guardian giving their consent for their child to travel without them.
  • Medical Records Release: a form giving permission to transfer your health records to a third party.
  • Cohabitation Agreement: a contract between an unmarried couple who wish to live together and combine their finances.
  • Separation Agreement: a contract containing the terms and conditions of a married couple's legal separation.

Frequently Asked Questions:

Child Medical Consent FAQ
Sample of LawDepot’s Child Medical Consent form


Child Medical Consent

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