Free Child Medical Consent

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Create Your Free Child Medical Consent

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  2. Email, download or print instantly
  3. Just takes 5 minutes

Child Medical Consent

Children


Children

Which children do you want listed on this form?

Child





Frequently Asked Questions
When can young people consent to medical treatment?- 18 years of age or older (adult): In England, Wales and Northern Ireland, parental responsibilities may be exercised until a young person reaches 18 years. In Scotland a child over the age of 16 is treated as an adult and may give their own medical consent.

- 16 to17 years of age (young people): People aged 16 or 17 are presumed to be capable of consenting to their own medical treatment, and any related procedures involved in that treatment, such as an anaesthetic (section 8 of the Family Law Reform Act 1969). However, unlike adults, the refusal of a competent person aged 16–17 may in certain circumstances be overridden by either a person with parental responsibility or a court. In England, Wales and Northern Ireland there are some procedures (e.g. live organ donation, some non-therapeutic procedures and research) where the presumption of competence for a person 16 or 17 years old also does not apply and parental consent would be needed. As mentioned above, in Scotland a person over the age of 16 is treated as an adult.

- 16 years of age or younger (children): A person under the age of 16 can be competent to give medical consent but this needs to be assessed in each case on a continual basis.

Note: In an emergency, where consent is unavailable, for example when the patient is unable to communicate his or her wishes and where nobody with parental responsibility is available, it is legally and ethically appropriate for health professionals to proceed with treatment necessary to preserve the life, health or well being of the patient.


Your Child Medical Consent

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AUTHORISATION TO CONSENT TO MEDICAL TREATMENT OF CHILD

  1. We, ____________________ and ____________________ of ________________________ 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 17 October 2018 at ________________________ and residing at ________________________

  2. We hereby authorise and appoint ____________________ of ________________________ as our agent. Our agent may consent to our child's
    1. transportation by ambulance
    2. examination
    3. x-rays
    4. diagnoses
    5. hospitalisation
    6. anaesthesia
    7. medication

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

  3. Our 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 our child. This power and authority will be effective as of the 17th day of October, 2018.
  5. We 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 our child's medical, mental health care and insurance providers, in writing, and the agent named above that we wish to revoke it.
  7. Any questions or concerns regarding this authorisation may be directed to us at:

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



NOTARY ACKNOWLEDGEMENT

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

Before me, (Notary's name) _______________________________

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

Address ___________________________

Telephone __________________________

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