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Child Medical Consent template free sample

Sample
Child Medical Consent

USA Child Medical Consent


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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 accurate and up to date! It was last reviewed by a lawyer in May 2013.


... or customize one below.


Governing Jurisdiction:

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

Select a State:

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:

Address:

City:

Country:

State:

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

Medical Information:

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

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

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

Health Care Providers:

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

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

Escort Information:

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

First Escort:

Address:

City:

Country:

State:

Zip Code:

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

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

Length of Consent:

This consent will become effective (e.g. January 17th, 2013):

This consent will END on (e.g. December 28th, 2013):

Signing Conditions:

Date of Signing:

Day (e.g. 2):

Month (e.g. January):

Year (e.g. 2013):

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:

State: