Free Child Medical Consent

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Child Medical Consent

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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 17 June 2018 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. My agent may have access to any and all records, including, but not limited to, insurance records regarding any medical services or treatment provided.
  4. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for my child. This power and authority will be effective as of the 17th day of June, 2018.
  5. I give this consent freely and knowingly in order to provide for the child and not as a result of coercion, duress or payments by any person or agency.
  6. 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.
  7. Any questions or concerns regarding this authorisation may be directed to me at:

    Name: ____________________
    Address: ________________________
    Phone Number: ____________________
    Secondary Phone: ____________________
    Email: ____________________

IN WITNESS WHEREOF, I hereunto sign my name at ____________________, England this 17th day of June, 2018.


_________________________________
____________________

 

NOTARY ACKNOWLEDGEMENT

Declared at (city) _______________________ on the 17th day of June, 2018.

Before me, (Notary's name) _______________________________

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

Address ___________________________

Telephone __________________________

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