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Minor (Child) Medical Consent Form

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Minor (Child) Medical Consent Form

Updated July 07, 2022

A minor (child) medical consent is a legal document providing someone other than the parent or legal guardian temporary rights to seek and provide healthcare and healthcare decisions on behalf of their child. Common individuals who receive such consent are grandparents, daycares, babysitters, teachers, step-parents, sports coaches, and trusted friends.

Supplemental Forms

Child Power of Attorney – In addition to handling the medical decisions of a child, a parent or guardian can assign other responsibilities such as educational powers and everyday caretaker.

Grandparent Consent to Minor (Child) – Specifically for grandparents who will have the legal right to choose the medical treatment for a minor (child).

When is it Needed?

A child medical consent form should be utilized when:

  • A parent or legal guardian would like to provide another entity or individual limited consent to obtain medical care for your child.
  • A parent or legal guardian would like to provide another entity or individual the ability to request medical attention for the child while under their care (i.e., babysitter, daycare).
  • The child will be in the temporary care of another individual or group (i.e., school teachers, church groups).

How to Give Medical Consent for a Child

Depending on the State, there may be certain laws that require the parent(s) or legal guardian(s) to grant power of attorney for a child instead of a simple medical consent.

Step 1 – Find a Competent Guardian

older woman receiving phone call

Utilizing a medical consent form for a child requires a fully competent individual. It will be imperative that the individual has the character and capability to understand the scope and capacity of the consent. This may require the guardian being available at all times in the chance they are needed to represent the best interests of the child.

Step 2 – Inform the Guardian of Child’s Medical Issues (if any)

woman explaining child's medical history to potential guardian

When requesting an individual to be a guardian, it will be ideal for them to fully understand the child’s medical history. Therefore, the parent(s) should ensure the child has had a recent appointment to certify that all vaccinations, allergies, medical history, surgery, current medications, health issues and/or concerns are up to date.

Step 3 – Inform the Guardian of the Child’s Medications

child's guardian taking notes of child's medical history

If there are any current prescriptions or medications that the child is on this should be included when reporting the child’s medical history to the guardian. Especially if the guardian is expected to oversee the child’s medical intake.

Step 4 – Determine an End Date

closeup of iPhone showing calendar

In most States, it is required that there is an end date to a child medical consent (usually 6 to 12 months). Otherwise, the hospital or medical facility may consider the guardianship invalid as permanent or recurring consent is required to be approved by a local court.

  • State Laws – A child’s medical consent falls under the jurisdiction of power of attorney.

Step 5 – Sign the Document

person signing minor medical consent form

The form is highly recommended to be authorized by the parent and a witness in the presence of a notary public. In the chance, this is not possible a third (3rd) party witness may be suitable, although, it is not guaranteed that it will be accepted by the healthcare facility.

Therefore, a notary acknowledgment should be added as an attachment with the form being authorized in the presence of a notary public.


How to Write

1 – This Template Should Be Downloaded When A Child’s Guardian Needs Consent

Once an individual who can be considered responsible to handle the health care of a Child (if necessary) when the Parent(s) or Current Guardian is unavailable, download this form in any of the formats defined on the buttons in the preview image’s caption area.

2 – Attend To The Requirements Of The Opening Statement

This document’s opening statement shall work to supply the purpose of its execution. Here, we will need to supply some supplement the structure of this declaration with the specific information it requires. To begin, the individual delivering consent to arrange for the Child’s Health Care must be identified. This can only be the Child’s Parent(s) or Legal Guardian(s). Document his or her Name on the first blank line (preceding the terms “…Parent Or Legal Guardian.” Note: Only the Courts can Appoint A Legal Guardian. Now, we must document some information to clearly identify the Child whose Health Care is at the focus of this document. Supply this Child’s Full Legal Name to the second blank line of this sentence. The next series of empty spaces have been placed in this statement so you may record the Birth Date of the Child. This Calendar Date should be furnished as a Two-Digit Calendar Day, the Name of the Month and the Two-Digit Calendar Year reported as the Child’s Birthday on his or her Birth Certificate. In cases where consent is being delivered by a Legal Guardian, the Child’s exact Birth Date or Birth Certificate may not be available. If so then consult the Court where this Child’s information has been documented (oftentimes, this is the Court that appointed the Legal Guardian) to access and report this information properly. Now, it will be time to officially name the individual who will have the Parent or Legal Guardian’s consent to seek Medical Care for the Child as necessary when the Child is in his or her Care. Use the empty space following the phraseology “…Under The Care Of” to present the Consent Recipient’s Full Name. In addition to the Consent Recipient’s Name, we should further document his or her Identity by producing the Address displayed on his or her I.D. Cards (i.e. Driver’s License). Use the next three blank spaces for this purpose by documenting the Consent Recipient’s Address, City, and State across them where appropriate.


3 – The Consent Granted To The Recipient Should Have A Time-Frame Of Effectiveness

The statement beginning with the words “This Authorization Is Effective From The” calls for the first Calendar Date when the Consent Recipient’s ability to handle the Child’s Medical Care (as required) to be furnished using the first three blank spaces. The last three blank spaces have been reserved to furnish the last Calendar Date when the Consent Recipient has the Parent/Legal Guardian’s Consent to seek Medical Care for the Child. Both Dates should be entered with the format of a Two-Digit Calendar Day, Month Name, and Two-Digit Calendar Year.


 4 – The Parent Or Current Guardian’s Signature Is A Mandatory Tool Of Execution

The final task to officially grant this type of Consent is the Dated Signature of the Parent or Legal Guardian. Only the individual with the right to grant this consent and whose Name appears above as the Child’s Parent or Legal Guardian may complete this task. He or she must sign the blank line labeled “Signature Of Parent Or Legal Guardian” then, on the adjacent line, record the Current “Date” of signing. This action should be performed by the Principal before at least one Witness. The Witness will need to sign the “Witness Signature” line then print his or her Name on the “Witness Name” line immediately after the Principal has signed the completed Consent document.


5 – Provide Some Background Information Regarding The Minor

Due to the nature of this paperwork, it would be considered wise to fill out the bottom portion of this page. The first part will require the Child’s “Family Address,” “Parent/Guardian Telephone Number,” and “Parent/Guardian Telephone Number.” If the Child’s Parents are deceased or unknown then, supply the Legal Guardian’s information to these lines. The next following lines are presented for the strict purpose of defining any nuances to the Child’s Health. First, record the Date when the Child received his or her “Last Tetanus” Vaccinations. Next, list each Allergy the Child is susceptible to on the line labeled “Allergies To Drugs Or Foods.” Locate the label “Special Medications, Blood Type Or Pertinent Information” then, supply any Medications the Child must take (i.e. Asthma Inhaler, Anti-Depressants, etc.), his or her Blood Type, and any information regarding the Child’s Health that should be made known at the time of treatment (i.e. Diabetes, Autism, etc.). In most cases, the Child will have a doctor of his or her own. If so, record this Doctor’s Name on the blank line labeled “Child’s Physician” along with his or her Contact Phone Number on the line labeled “Phone.” If the Child has Health Insurance, then supply the Insurance Company Name on the line attached to the label “Insurance” and make sure to record the Insurance Policy Number on the “Policy #” line. Finally, if the Parent or Legal Guardian issuing this consent prefers the Child be treated in a specific Health Care Facility then, record the name of this Health Care Facility on the blank space labeled “Preferred Hospital.”