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[Free Child Medical Consent Documents]

USA 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 up to date! It was last reviewed by a lawyer in September 2014.


... or customize one below.


Governing Jurisdiction:

This document will be governed by the laws of which nation?
Select a State:

Parent/Guardian Information:

How many legal guardians does the child(ren) have?
 

First Guardian's Information:

First Guardian's Name:

First Guardian's Residence:

During this consent, I can be reached:
Address:
City:
State/Province:
Postal/Zip Code:

Contact Information:

Home Phone (e.g. (302) 472-7392):
Work Phone:
Mobile Phone:
Fax:
E-mail:
 

Second Guardian's Information:

Second Guardian's Name:

Second Guardian's Residence:

During this consent, I can be reached:
Address:
City:
State/Province:
Postal/Zip Code:

Contact Information:

Home Phone (e.g. (302) 472-7392):
Work Phone:
Mobile Phone:
Fax:
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?

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
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?

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
Is your child on any medication?
Yes No
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:
State/Province:
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:
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, 2014):
This consent will END on (e.g. December 28th, 2014):
 

Signing Conditions:

Date of Signing:

Day (e.g. 2):
Month (e.g. January):
Year (e.g. 2014):

Witnesses:

Will this document be signed in front of two witnesses?
Yes No
Will a notary public be present?
Yes No