Canadian Child Medical Consent
Change Version: USA

PDF Child Medical Consent Form

A Child Medical Consent is used to give a third party the power to authorize the provision of emergency care, medical and dental procedures, and/or other health care treatments to your child. It also contains information related to your child’s medical history (such as allergies and medications) and the contact information of his/her family health care providers.

More about Child Medical Consent legal forms.

  • Proceed through this form, providing as much information as possible.
  • Do not use the '&' (ampersand) and '"' (double-quotation mark) characters.
  • When you are done, click on 'Build Document' at the bottom.

Parent/Guardian Information:

A child's legal guardian is the person they live with, and who takes care of them. In most cases, this is the parents, or a single parent if there is not joint custody.
How many legal guardians does the child(ren) have?

First Guardian's Information:

First Guardian's Name:

First Guardian's Residence:

Select "At home or at work" if you will be around your area of residence.
During this consent, I can be reached:

Name (e.g. Hotel name, friend's name, etc):

Address:

Address:

City:

City:

Country:

Country:

State:

State:

Province:

Province:

Country:

Country:

Zip Code:

Zip Code:

Contact Information:

Contact Information:

Home Phone (e.g. (302) 472-7392):

Home Phone (e.g. (302) 472-7392):

Work Phone:

Work Phone:

Mobile Phone:

Mobile Phone:

Fax:

Fax:

E-mail:

E-mail:

Second Guardian's Information:

Second Guardian's Name:

Second Guardian's Residence:

During this consent, I can be reached:

Name (e.g. Hotel name, friend's name, etc):

Address:

Address:

City:

City:

Country:

Country:

State:

State:

Province:

Province:

Country:

Country:

Zip Code:

Zip Code:

Contact Information:

Contact Information:

Home Phone (e.g. (302) 472-7392):

Home Phone (e.g. (302) 472-7392):

Work Phone:

Work Phone:

Mobile Phone:

Mobile Phone:

Fax:

Fax:

E-mail:

E-mail:

Number of Children:

How many children do you wish to give a consent for?

First Child's Information:

Personal Information:

Full Name (e.g. George Robert Smith):

Gender:

Age:

Date of Birth (e.g. June 12th, 1999):

Place of Birth (e.g. Toronto, Canada):

Social Security Number:

Place of Residence:

Does this child live with the above guardian(s)?
 Yes No

Which guardian?

Where does the child reside?

Address:

City:

Country:

Province:

State:

Country:

Zip Code:

Medical Information:

Do you wish to include your child's blood type?
 Yes No

Select the blood type:

Do you wish to include your child's Rh Factor?
 Yes No

Select the Rh type:

Is your child on any medication?
 Yes No

Provide a detailed description of the medication(s):


Does your child have other illnesses or conditions?
 Yes No

Provide a detailed description of the condition(s):


Do you wish to provide health insurance details for this child?
 Yes No

Describe the health insurance:


Second Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Social Security Number:

Place of Residence:

Does this child live with the above guardian(s)?
 Yes No

Which guardian?

Where does the child reside?

Address:

City:

Country:

Province:

State:

Country:

Zip Code:

Medical Information:

Do you wish to include your child's blood type?
 Yes No

Select the blood type:

Do you wish to include your child's Rh Factor?
 Yes No

Select the Rh type:

Is your child on any medication?
 Yes No

Provide a detailed description of the medication(s):


Does your child have other illnesses or conditions?
 Yes No

Provide a detailed description of the condition(s):


Do you wish to provide health insurance details for this child?
 Yes No

Describe the health insurance:


Third Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Social Security Number:

Place of Residence:

Does this child live with the above guardian(s)?
 Yes No

Which guardian?

Where does the child reside?

Address:

City:

Country:

Province:

State:

Country:

Zip Code:

Medical Information:

Do you wish to include your child's blood type?
 Yes No

Select the blood type:

Do you wish to include your child's Rh Factor?
 Yes No

Select the Rh type:

Is your child on any medication?
 Yes No

Provide a detailed description of the medication(s):


Does your child have other illnesses or conditions?
 Yes No

Provide a detailed description of the condition(s):


Do you wish to provide health insurance details for this child?
 Yes No

Describe the health insurance:


Fourth Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Social Security Number:

Place of Residence:

Does this child live with the above guardian(s)?
 Yes No

Which guardian?

Where does the child reside?

Address:

City:

Country:

Province:

State:

Country:

Zip Code:

Medical Information:

Do you wish to include your child's blood type?
 Yes No

Select the blood type:

Do you wish to include your child's Rh Factor?
 Yes No

Select the Rh type:

Is your child on any medication?
 Yes No

Provide a detailed description of the medication(s):


Does your child have other illnesses or conditions?
 Yes No

Provide a detailed description of the condition(s):


Do you wish to provide health insurance details for this child?
 Yes No

Describe the health insurance:


Fifth Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Social Security Number:

Place of Residence:

Does this child live with the above guardian(s)?