Grandparent Medical Consent (For a Minor)

Parent's Information

Use this form as a Parent or Guardian to allow a Grandparent to have the the rights to make health care decisions on your child for a temporary period.

Name of the Parent or the Legal Guardian

First

Last

Parent's Contact

Enter the Phone Number of Parent / Legal Guardian 1:

This should be the parent or legal guardian named on the form.

Enter the Phone Number of Parent / Legal Guardian 2:

The Grandparent (The Caretaker)

Enter Grandparent's Name

First

Last

This is the person that will be handling the minor's health care decisions if or when the parent or legal guardian is not available

Period of Time (Medical Consent)

Has to have a set term.

Enter Date

Starting Date

Enter Date

Ending Date

Minor's Name

Enter the Name of the Minor

First

Last

Minor's Address

Street Address

Address Line 2

City

State

ZIP Code

Minor's Birthday

Enter Minor's Birthday

Minor's Medical Background

Describe Special Medications, Blood Type or Pertinent Information

List Child's Allergies if any

If there are NO Allergies please type "None".

Child's Primary Care Physician

Enter Physician's Name

Dr.

Enter Physician's Phone Number

Insurance Information

Enter Insurance Name

Enter Policy Number

Date

Enter the Date of this Medical Consent for a Minor

E-Signatures

If the Parties are not available to Electronically Sign below then click 'Save' and it can be signed after printing.

Signature of Parent or Legal Guardian

Clear

Print Name

Signature of Witness

Clear

Print Name