Medical Consent Form for Minor Template

This Minor (Child) Medical Consent was signed on  .

AUTHORIZATION AND TREATMENT

I,  , an individual having a usual place of living at  , affirm that I am the parent of   born on   (the "Child").

I hereby consent to and authorize  , an individual having their usual place of living at   (the "Decision Maker"), to consent to the following treatments for the Child:

I grant the Decision Maker the authority to consent to and authorize any medical care outlined above as may be deemed necessary or advisable by a licensed medical or healthcare professional in the diagnosis and treatment of the Child.

The Decision Maker should ensure that this Minor (Child) Medical Consent is presented at the hospital or physician's office whenever the Child seeks treatment.

CHILD INFORMATION

Health Data

• Blood type:  .

Medical Care and Insurance Information

• Preferred medical facility:  , located at  
  
  
• Insurer:  ; policy number:  ; policyholder:  .

EMERGENCY CONTACT PERSONS

First emergency contact person. If the Decision Maker has any questions regarding this Minor (Child) Medical Consent, they should contact me at the following contact information:

• Phone number:  
• Email:  

Second emergency contact person. If I do not respond to the Decision Maker's questions regarding this Minor (Child) Medical Consent, they should contact the second emergency contact person at the following contact information:

• Emergency contact's name:  
• Phone number:  
• Email:  

DURATION

This Minor (Child) Medical Consent is valid when the Child is in the care of the Decision Maker from   to  .

Signature: _________________________

Name:  

Witness 1

Signature: _________________________

Name:  

Address:  

Phone number:  

Witness 2

Signature: _________________________

Name:  

Address:  

Phone number: