"Child Medical Consent Form"

What Is a Child Medical Consent Form?

When parents are in the process of hiring a babysitter or daycare center to help care for their children it is important that they complete a Child Medical Consent Form on behalf of the party who will be watching the child.

Alternate Names:

  • Medical Consent Form for Minor;
  • Minor Medical Consent Form.

Having this type of form will provide the guardian with the necessary information to contact a medical professional that will know the child's medical history. A free printable Child Medical Consent Form can be downloaded below. This form can be part of a Child Care Contract or Nanny Contract and allows a person or party who is not a legal guardian or parent to seek medical assistance in case of an emergency on behalf of the child.

Additionally, you can also have a third-party caregiver complete a Child Travel Consent Form if they will be expected to frequently travel with your child while you are not present. And any expenses they may incur while caring for the child can be recorded in a Child Care Receipt.

ADVERTISEMENT

How to Give Medical Consent for a Child?

Make sure to include the following information to create a Child Medical Consent Form:

  1. Begin by stating that you - as the parent of the child - grant the ability to determine Child Medical Consent by [The Third Party Person or Daycare] while the child is under their care. Include what medical care you agree to give the third party consent over. State that any medical treatment must also be deemed necessary by a physician or medical professional; If there are any specific topics (such as the right to Do Not Resuscitate) that you do not approve of the caretaker to be in charge of, make sure this is stated as well.
  2. Provide the contact information and mailing address where the third party is located.
  3. Provide the contact information and mailing address of you and your partner in case an emergency should arise. This will allow a physician to contact you immediately in case an emergency should arise.
  4. Include a list of the child's vaccination records, allergies (such as food, drugs, or animals), and any additional medical details. If the child will need to have emergency medicine available to them at all times include the name of the drug, how it should be administered, and who to contact to alert the parents or the child's primary physician. If the child is old enough to administer the drug themselves, include this information and what the caregiver should do once the child has taken the drug.
  5. Provide the name, contact information, insurance information, and preferred hospital of the child's physician. If this permission is temporary, include the date that this contract will be terminated.
  6. Provide a signature section for yourself, the guardian, and a third witness with date sections. Be sure to provide a copy for each person signing the document and maintain at least two copies for yourself for record-keeping.

Not what you were looking for? Check out these related topics:

ADVERTISEMENT

Download "Child Medical Consent Form"

Download PDF

Fill PDF online

Rate (4.8 / 5) 8 votes
Child Medical Consent Form
I, ___________________, am the parent or legal guardian of ___________________,
born on ___________________, do hereby consent to any medical care and the
administration of ___________________ determined by a physician to be necessary
for the welfare of my child while said child is under the care of:
_____________________________________________________________________
Name of Facility
_____________________________________________________________________
Address of Facility
This authorization is effective from __________________ to ___________________.
_________________________________
_________________________________
Parent’s or Legal Guardian’s Printed Name
Witness Printed Name
_________________________________
_________________________________
Parent’s or Legal Guardian’s Signature
Witness Signature
_________________________________
_________________________________
Date
Date
This consent form should be taken with the child to the hospital or physician's office
when the child is taken for treatment. This additional information will assist in
treatment if it can be furnished with the consent but is not required.
________________________________
________________________________
Home Phone Number
Mobile Phone Number
_____________________________________________________________________
Family Address
Allergies to drugs or foods, perscribed medications, blood type:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_______________________________
_______________________________
Primary Doctor’s Name
Primary Doctor’s Phone Number
_____________________________________________________________________
Insurance Company and Policy Number
©
TEMPLATEROLLER.COM
Child Medical Consent Form
I, ___________________, am the parent or legal guardian of ___________________,
born on ___________________, do hereby consent to any medical care and the
administration of ___________________ determined by a physician to be necessary
for the welfare of my child while said child is under the care of:
_____________________________________________________________________
Name of Facility
_____________________________________________________________________
Address of Facility
This authorization is effective from __________________ to ___________________.
_________________________________
_________________________________
Parent’s or Legal Guardian’s Printed Name
Witness Printed Name
_________________________________
_________________________________
Parent’s or Legal Guardian’s Signature
Witness Signature
_________________________________
_________________________________
Date
Date
This consent form should be taken with the child to the hospital or physician's office
when the child is taken for treatment. This additional information will assist in
treatment if it can be furnished with the consent but is not required.
________________________________
________________________________
Home Phone Number
Mobile Phone Number
_____________________________________________________________________
Family Address
Allergies to drugs or foods, perscribed medications, blood type:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_______________________________
_______________________________
Primary Doctor’s Name
Primary Doctor’s Phone Number
_____________________________________________________________________
Insurance Company and Policy Number
©
TEMPLATEROLLER.COM