Free Child Medical Consent

Free Child Medical Consent

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Create Your Free
Child Medical Consent

  1. Answer a few simple questions
  2. Email, download or print instantly
  3. Just takes 5 minutes

Child Medical Consent

Create your Child Medical Consent

Create your Child Medical Consent


Information of parent/guardian




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Frequently Asked Questions
Who is a guardian?A guardian is an individual who has the right to make decisions on behalf of the child. The guardian is generally appointed by local law or court order, or upon the death of a parent by that parent's will.Do I need both parents signing?Unless there was no father, or one of the parent has died, or you have an order granting full custody, you should have both parents signing the document.


Your Child Medical Consent

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AUTHORISATION TO CONSENT TO MEDICAL TREATMENT OF CHILD

  1. I, ____________________ of ____________________, ____________________, __________, __________, ____________________ make oath and say that I am the lawful guardian of the child listed below and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.

    Information of Child

    ____________________, male, born January 16, 2017 at ____________________ and residing at ____________________, ____________________, __________, __________, ____________________.


  2. I hereby authorise and appoint ____________________ of ____________________, ____________________, __________ __________ as my agent. My agent may consent to my child's
    1. transportation by ambulance
    2. examination
    3. x-rays
    4. diagnoses
    5. hospitalisation
    6. anaesthesia
    7. medication

    I do not authorise ____________________ to consent to the transfusion of blood.

  3. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for my child and this power and authority will be effective as of the 16th day of January, 2017.
  4. I give this consent freely and knowingly in order to provide for the child and not as a result of pressure, threats or payments by any person or agency.
  5. This consent will remain in effect until it is revoked by notifying my child's medical, mental health care and insurance providers, in writing, and the agent named above that I wish to revoke it.
  6. Any questions or concerns regarding this authorisation may be directed to me at:

    Name: ____________________
    Street Address: ____________________
    City, Region: ____________________, __________
    Postcode: __________
    Country: ____________________

    Home Phone: __________
    Work Phone: __________
    Cell Phone: __________
    Email: ____________________


IN WITNESS WHEREOF, I hereunto sign my name at ____________________, ____________________16th day of January, 2017.


____________________

 

Witness

 

Witness

     

Print Name

 

Print Name


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