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Canadian Child Medical Consent

Canada Child Medical Consent


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Canadian Child Medical Consent

[What is a Child Medical Consent?]

Simply answer the questions below to personalize your Child Medical Consent

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.

This document is accurate and up to date! It was last reviewed by a lawyer in February 2012.


... or customize one below.


Governing Jurisdiction:

This agreement will be governed by the laws of which Nation?

Select a State:

Select a Province or Territory:

Select a State / Territory:

Select a Country:

Select a Region:

Select a State or Union Territory:

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.

If both parents live together, select ONE legal guardian and type both parent's names in the name box.
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:

Select a Country:

Select a Country:

Select a State / Territory:

Province:

Province:

Select a State or Union Territory:

Select a State or Union Territory:

Country:

Country:

Postal/Zip Code:

Postal/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:

Select a Country:

Select a Country:

Select a State / Territory:

Select a State / Territory:

Province:

Province:

Select a State or Union Territory:

Select a State or Union Territory:

Country:

Country:

Postal/Zip Code:

Postal/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):

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:

Select a Country:

Select a State / Territory:

Select a Region:

Select a State or Union Territory:

Country:

Postal/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:

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:

Select a Country:

Select a State / Territory:

Select a Region:

Select a State or Union Territory:

Country:

Postal/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:

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:

Select a Country:

Select a State / Territory:

Select a Region:

Select a State or Union Territory:

Country:

Postal/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:

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:

Select a Country:

Select a State / Territory:

Select a Region:

Select a State or Union Territory:

Country:

Postal/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:

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:

Select a Country:

Select a State / Territory:

Select a Region:

Select a State or Union Territory:

Country:

Postal/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:


Sixth Child's Information:

Personal Information:

Full Name:

Gender:

Age:

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

Place of Birth:

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:

Select a Country:

Select a State / Territory:

Select a Region:

Select a State or Union Territory:

Country:

Postal/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:


Health Care Providers:

Do you wish to list your family doctor's contact information?
 Yes No

Name:

Address:

City:

Country:

Zip:

Phone (e.g. (294) 395-4839):

Emergency Phone (e.g. (305) 396-6945):

Do you wish to list your family dentist's contact information?
 Yes No

Name:

Address:

City:

Country:

Zip:

Phone (e.g. (294) 395-4839):

Emergency Phone (e.g. (305) 396-6945):

Escort Information:

How many escorts will have authority over your child(ren)'s health care?

First Escort:

Second Escort:

Address:

City:

Country:

Province:

State:

Select a Country:

Select a State / Territory:

Select a Region:

Select a State or Union Territory:

Country:

Zip Code:

Do you wish to limit the authority of the escort(s)?
 Yes No

How many limits do you wish to impose?

Specify anything do NOT want your escort(s) to consent to, E.g. Blood transfusion, X-rays, etc.

First Item:

Second Item:

Third Item:

Fourth Item:

Fifth Item:

Do you wish to limit the location(s) that this document is effective in?
 Yes No

Which locations will this document be VALID in?


Length of Consent:

This consent will become effective (e.g. January 17th, 2012):

This consent will END on (e.g. December 28th, 2012):

Signing Conditions:

Date of Signing:

Day (e.g. 2):

Month (e.g. January):

Year (e.g. 2012):

Witnesses:

We highly recommend the presence of a notary public and two witnesses at the signing of this document, to ensure its validity.
Will this document be signed in front of two witnesses?
 Yes No

Will a notary public be present?
 Yes No

Country of Signing:

Province:

State:

Select a Country:

Select a State / Territory:

Select a State or Union Territory:

Select a Region:

Country: