Free Child Medical Consent

Free Child Medical Consent

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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

Frequently Asked Questions
What is a Child Medical Consent?A Child Medical Consent form is used by parents or guardians of minor children to grant authorization for another adult, such as a grandparent or child care provider, to make medical decisions for the minor child on their behalf.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 by a deceased parent's will.Do both parents/guardians need to sign this Child Medical Consent form?Both parents should sign the Child Medical Consent form unless it is a single parent family or one parent has full custody of the minor.

Your Child Medical Consent

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AUTHORISATION TO CONSENT TO MEDICAL TREATMENT OF CHILD

  1. We, ____________________ and ____________________ of ____________________, ____________________, England, United Kingdom of Great Britain and Northern Ireland, __________ make oath and say that we are the lawful guardians of the child listed below and there are no court orders now in effect that would prohibit us from conferring the power to consent upon another person.

    Information of Child

    ____________________, male, born 26 June 2017 at ____________________ and residing at ____________________, ____________________, England, United Kingdom of Great Britain and Northern Ireland, __________.


  2. We hereby authorise and appoint ____________________ of ____________________, ____________________, England, United Kingdom of Great Britain and Northern Ireland, __________, as our agent. Our agent may consent to our child's surgical, dental, developmental, mental health and/or
    1. transportation by ambulance
    2. examination
    3. x-rays
    4. diagnoses
    5. hospitalisation
    6. anaesthesia
    7. surgery
    8. medication
    9. transfusion of blood or blood products

    Our agent may have access to any and all records, including, but not limited to, insurance records regarding any such services.

  3. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for our child and this power and authority will be effective as of the 26th day of June, 2017.
  4. We 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 our child's medical, mental health care and insurance providers, in writing, and the agent named above that we wish to revoke it.
  6. Any questions or concerns regarding this authorisation may be directed to us at:

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

    Phone Number: __________
    Secondary Phone: __________
    Email: ____________________

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

    Phone Number: __________
    Secondary Phone: __________
    Email: ____________________

IN WITNESS WHEREOF, we hereunto sign our names at ____________________, England this 26th day of June, 2017.


____________________

 

____________________



NOTARY ACKNOWLEDGEMENT

Declared at (city) _______________________ on the 26th day of June, 2017.

Before me, (Notary's name) _______________________________

Signature ____________________________________ (Seal)
NOTARY PUBLIC IN AND FOR THE COUNTY OF , ENGLAND

Address ___________________________

Telephone __________________________

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