Child Medical Consent Form

With a child medical consent form, you can be able to leave your child (ren) in the care of others thus, enabling your child’s caregiver to be able to access emergency medical care for your child. A child medical consent form gives specific details on the child which are deemed relevant for any treatment to be provided. Below is a sample child medical consent form.

Sample Child Medical Consent Form

Parent’s/guardian’s name: _______________________________________________

Parent/guardian’s information: _______________________________________________

Address: _______________________________________________

State/town: _______________________________________________

Telephone number: _______________________________________________

Where can you be contacted in case of an emergency?

_________________________

Would you consent to emergency transfusion for your child (ren)

_________________________

I authorize the guardian to consent to any of the following health treatments for my child (ren)

_________________________

_________________________

_________________________

Do you authorize your temporary guardian access to any medical insurance records related to the health care treatment of your child (ren)?

_________________________

Number of children: _______________________________________________

Name of the child: _______________________________________________

Date of birth: _______________________________________________

Age: _______________________________________________

Gender: _______________________________________________

Please provide your health insurance information:

_________________________

_________________________

Is the child currently on any medication?

_________________________

Allergies or any other information?

_________________________

Child’s blood group: ____________________

This form is effective from date: _____________________________

To date: __________________________

Details of family physician:  ____________________________

Witnesses:  ____________________________________

Consent forms

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