Child Medical Consent Form
  • Consent Form Details
    • Parents/Legal Guardian
    • Children Details
    • Authorized Person
    • Medical Treatments
    • Miscellaneous
  • Complete the Document
    • Template's Format

Parents/Legal Guardian

  • This consent medical form is signed by:

  • Indicate the full name of one parent:

  • Indicate the full residential address of one parent:

  • Indicate the full name of first parent:

  • Indicate the full name of second parent:

  • Indicate the full residential address, where both parents currently live:

  • Indicate the full name of a legal guardian:

  • Indicate the full residential address of a legal guardian:

  • Emergency contact details (phone and email) of the parent(s)/legal guardian:

Children Details

  • Indicate the full name of insurance company:

  • Indicate the insurance's policy number:

  • This medical consent form is issued for:

  • Indicate the full name of a child:

  • Indicate the child's date of birth:

  • Indicate the full name of a first child:

  • Indicate the date of birth of a first child:

  • Indicate the full name of a second child:

  • Indicate the date of birth of a second child:

  • Indicate the full name of a third child:

  • Indicate the date of birth of a third child:

  • Indicate the full name of a fourth child:

  • Indicate the date of birth of a fourth child:

  • Indicate the full name of a fifth child:

  • Indicate the date of birth of a fifth child:

Authorized Person

  • Indicate the full name of a person to whom this consent is provided ("authorized person"):

  • Indicate the full business address of the authorized person:

  • Select the state, where the authorized person usually resides:

  • This medical consent form becomes effective on:

  • This medical consent form remains in force:

  • Select the date on which this medical consent form shall expire:

Medical Treatments

  • Does the parent/legal guardian consent to necessary medical treatments/procedures in case of emergency?

  • Does the parent/legal guardian consent to obtain routine medical treatments/procedures in the best interest of a child?

  • Does the parent/legal guardian consent to administration of medication to a child?

  • Does the parent/legal guardian consent to administration over the counter medications?

  • Does the parent/legal guardian wish to consent to any other additional medical treatments and procedures?

  • List all the additional medical treatments/procedures to which the consent is provided:

Miscellaneous

  • Does a child/children have any special needs (e.g., allergies, autism etc.)?

  • Describe in detail child/children's special needs:

  • If hospitalization is required, does the parent/legal guardian wish to indicate a preferred medical facility?

  • Indicate the full name and address of a preferred medical facility:

  • Does the parent/legal guardian wish to indicate a preferred healthcare provider?

  • Indicate the full name and contact details of a preferred healthcare provider:

Select a template's format:

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